The GOP Pulled Off the Medicaid Bandaid. Next Up? Medicare Amputations.

In this post we’re going to look at the growing right wing “Health Care Compact” movement that would transfer Medicare from a federally run program to a state-run enterprise incapable of dealing with economic shocks (which isn’t very useful for a safety-net program). We’ll also take a look at what we can expect should the “Health Care Compact” come into force by reviewing Kansas’ recent Medicaid privatization schemes and the FBI investigations that have followed. And finally, we’ll look at the origins of the Health Care Compact. Hint: it’s the kind of plan that gets hatched when someone like Ted Cruz catches nullification fever.

Hospital officials say refusal to expand Medicaid will hurt their bottom lines
Money needed to offset other cuts coming because of Obamacare

By Jim McLean
KHI News Service
Jan. 13, 2014

PARSONS — For Jodi Schmidt and other hospital administrators across Kansas, Medicaid expansion is a critical business issue not a political one.

Schmidt is chief executive of Labette Health, a 99-bed regional medical center that serves Parsons and several surrounding communities in southeast Kansas. She said the money being lost because of the decision by Gov. Sam Brownback and legislators to not participate in the first year of expansion could mean the difference between the hospital finishing the year in the black or with a deficit.

“Whatever your politics, the reality on the ground for hospitals is that Medicaid expansion is critically important for us,” Schmidt said.

Expansion could provide coverage to an estimated 85,000 Kansans who make too much to qualify for the state’s existing Medicaid program — called KanCare — but too little to be eligible for federal tax credits to help them purchase private coverage on the Healthcare.gov exchange.

A study done last year for the Kansas Hospital Association estimated that expanding eligibility to the level called for in the Affordable Care Act would increase federal Medicaid spending in the state by $3 billion between this year and 2020. The federal government has pledged to pay the full cost of covering the expansion population for three years and no less than 90 percent thereafter.

Expansion would provide Labette Health and other hospitals in the association’s southeast district an additional $2.7 million a year to share.

The money is needed, Schmidt said, to partially offset anticipated Medicare cuts and looming reductions in federal payments that help hospitals offset the cost of caring for the uninsured.

“We could be seeing an additional $1.7 or $1.8 million in reduced reimbursement next year,” Schmidt said. “And so this lack of Medicaid expansion is just one more hit and there is only so much individual hospitals can bear.”

Forty miles up U.S. Highway 59 from Parsons the story is much the same in Chanute. There, Dennis Franks, the CEO of the 25-bed Neosho Memorial Regional Medical Center, said the hospital needs the money that would come with Medicaid expansion to offset cuts in other reimbursements.

“When you live on the margin every dollar counts,” Franks said. “So, when I’m taking $700,000 to $1 million a year out of my budget that means there are services I can no longer provide. What am I going to do to make sure that I keep my doors open and do the things for this community that I need to do?”

Via Christi Regional Medical Center in Wichita may be the Kansas hospital most affected by the state’s reluctance to participate in the Medicaid expansion. Last year, it received nearly $13 million in so-called disproportionate share payments to help offset some of the costs of caring for the uninsured. Starting next year, those payments will be steadily reduced along with Medicare reimbursement rates.
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Note that Wichita also happens to be the headquarters of Koch Industries, so this is the Kochs’ backyard that’s shooting itself in the foot while refusing insurance.

Continuing…

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That prospect has put Via Christi at the forefront of an effort being mounted by the hospital association to work out a Medicaid expansion compromise with the Brownback administration and Republican legislative leaders.

“We’ve made some progress with the public and with some legislators in making the case for Medicaid expansion,” said Bruce Witt, director of legislative affairs at Via Christi. “We’re at the point now where politics has kind of come into play and that’s where the real challenge lies.”

Put simply, the challenge is getting Brownback and legislators to decouple the expansion issue from Obamacare, which remains anathema to the Republican Party’s base and unpopular with most Kansans, assuming the polls are accurate.

The hospital association has hired former U.S. Health and Human Services Secretary Mike Leavitt, a Republican who served in the Bush administration, to try to persuade Kansas Republican leaders to move forward with expansion using a private-sector approach similar to those being developed or implemented in Arkansas, Iowa, Pennsylvania and a handful of other states.

Witt said he is hopeful progress can be made if expansion advocates with Leavitt’s help can “engage the business community.”

Mike O’Neal, chief executive of the Kansas Chamber, confirmed the business organization is willing to participate in such talks.

“I can’t predict at the end of the day whether that discussion will bear fruit in a way that the people who want the expansion are going to be satisfied,” O’Neal said. “But the discussion of an issue this important is healthy and it should take place.”
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Both O’Neal and Senate President Susan Wagle, a Wichita Republican, have said they expect the messy rollout of the ACA will make the expansion discussion more difficult. But both said they would be open to Kansas pursuing a plan like the one Pennsylvania officials are seeking federal approval to implement.

“I’m intrigued by the Pennsylvania plan because it has a work component to it,” O’Neal said. “They are actually trying to change the profile of the Medicaid population and incentivize some that are in that population to get into a work situation.”

Approximately 45 percent of uninsured Kansans in the Medicaid eligibility gap are employed, according to the Kansas Health Institute, a nonpartisan research and policy organization that includes the editorially independent KHI News Service.
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Yes, the proposed Medicaid expansion plan for Pennsylvania that has the Kansas GOP and Chamber of Commerce so intrigued was to make Pennsylvania the only first state to impose of work-search requirement (even though 45% of uninsured Kansans in the “gap” are already employed). So the swelling ranks of the long-term unemployed (that rarely ever find work again in the US economy) get keep swelling but at least they might have healthcare coverage as long as they continue looking for non-existent jobs. Pennsylvania’s governor has since watered down his work-requirement proposal while he awaits for federal approval so it remains to be seen if that will come into effect. But it’s a ruling states still suffering from Obamacare Derangement Syndrome are going to be watching closely and, as such, we should all probably watch how that develops too.

The GOP’s Death Sentence For America Health Care Compact
But that doesn’t mean no changes are on the way for Kansas and a collection of other states that also have governors suffering from Bad-Samaritanitis: A multi-state “compact” is already in the works and Kanas just joined it: Kansas, along with eight other states that have refused to expand Medicaid, wants to create a “Health Care compact” that will allow these states to completely take over the management of Medicaid AND Medicare. So the states that are refusing to take on the responsibily of ensuring their residents’ basic needs are met, want a lot more responsibilty over those basic needs:

Brownback signs controversial health care compact bill
Goal is to give member states control over Medicare and Medicaid

By Dave Ranney
KHI News Service
April 23, 2014

TOPEKA — Gov. Sam Brownback has signed into law a bill that might make it possible for Kansas to join a compact of states that want the power to run Medicare and Medicaid within their borders.

The new law also creates the possibility that the compact states could circumvent several key provisions in the Affordable Care Act, also known as Obamacare.

“The Health Care Compact will allow states to restore and protect Medicare for generations to come,” Brownback said in a prepared statement today announcing that he had signed the measure. The actual signing was Tuesday.

The compact couldn’t come into being without approval by Congress, which is considered unlikely as long as Democrats control at least one of its chambers. Democrats currently control the Senate, and Republicans are pushing hard in this year’s elections to regain the majority. The GOP already controls the U.S. House.

Kansas Insurance Commissioner Sandy Praeger and AARP Kansas had earlier urged the governor not to sign House Bill 2553, calling the initiative frivolous and misguided.

‘Really twisting things’

In a statement released today, the governor accused Obamacare of “cutting $700 billion out of Medicare,” a claim being used by Republicans across the nation as they continue to fight the law and campaign for election. Politifact, a fact-checking project of the Tampa Bay Times, has labeled the claim a half-truth.

According to Politifact, the law doesn’t actually cut Medicare spending but is expected to reduce future growth in the program’s costs mostly by reducing Medicare Advantage, “a small subset of Medicare plans that are run by private insurers.”

“The governor is really twisting things,” said Dave Wilson, a past volunteer president of AARP Kansas.

Wilson also said he doubted Brownback’s assurances that he would oppose any reduction in Medicare benefits, if the compact were enacted and state officials gained control over Medicare, which currently is administered solely by the federal government.

“That’s what he says and that’s what legislators who support this say,” Wilson said. “But the reality is they can’t do it now, but with this bill they could do it and that could have a tremendous impact on seniors, on the disabled and on veterans.”

Federal offiicals run the Medicare program, which provides health coverage for seniors. But Medicaid, which serves poor children, the frail elderly and the disabled, is a shared state-federal program with the federal government paying the majority of its cost (about 60 percent) and imposing various basic requirements on the states.

But Medicaid also gives states significant latitude in the ways they manage the program, including the determination of eligibility standards. For example, Kansas operates its KanCare program with a waiver exempting it from many of the standard Medicaid rules. And Kansas also is allowed to keep thousands of people out of Medicaid who would qualify for the program in other states.

One of nine

Kansas is one of nine states that have enacted laws expressing the desire to join the so-called “health care compact.” The others are Alabama, Georgia, Indiana, Missouri, Oklahoma, South Carolina, Texas and Utah.

“All nine states that are now in this compact are states that have turned their backs on Medicaid expansion,” Praeger said. “On the one hand you’re saying you want to bring those federal (Medicare) dollars back to Kansas, but on the other hand you’re saying we’re not going to take those (Medicaid) federal dollars.”

It’s unclear whether Kansas seniors will support the governor’s decision to sign the bill, she said.

“If it ain’t broke don’t fix it,” Praeger said. “And the Medicare program, while it needs to rein in costs, is a reliable source of health care services for our senior population, and I would not want to be putting those folks at risk.”

Americans for Prosperity, a political action group tied to the billionaire brothers Charles and David Koch, has spent millions of dollars fighting Obamacare.

“Health care decisions should be made by Kansas officials, not the federal government,” said Jeff Glendening, state director of Americans for Prosperity-Kansas. “With Congressional approval, the Health Care Compact will transfer control of federal health care funding from Washington, D.C., to Kansas. It supports the state’s ability to control its own health care system.”

Glendening said the compact wouldn’t require the states to take over Medicare or Medicaid but would allow them the option.

“Under the compact, we can set standards and reimbursement rates rather than handing those important decisions over to the federal government,” he said.

‘Path out of Obamacare’

The Libertarian Party of Kansas also endorsed the new law.

“We believe in government at its most local level,” said Al Terwelp, chairman of the state party. “So we support the compact idea in general, having the state of Kansas be in as much control over health care issues as possible.

In the Legislature, the bill’s primary sponsors were Rep. Brett Hildabrand and Sen. Mary Pilcher-Cook, both Republicans from Shawnee and opponents of Obamacare.

“By signing the health care compact, the governor has agreed Kansas needs to protect Medicare for seniors, while also providing a path for Kansas citizens and businesses out of Obamacare, giving Kansans more economic stability, freedom and choices for their health care needs,” Pilcher-Cook wrote in an email to KHI News Service.

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Uh oh! Kansas’ seniors (and Alabama’s, Georgia’s, Indiana’s, Missouri’s, Oklahoma’s, South Carolina’s, Texas’s and Utah’s seniors) might be in for quite the rude awakening, because the GOP’s “solution” to Obamacare appears to be the subversion of Medicare. Well, ok, that only happens if the GOP takes control of the Senate in 2014, but since that is a very real possibility….Uh Oh!

What Might God’s Governor do to Medicare? Let’s See…
Of course, if you take Brownback at his word, Kansans shouldn’t be concerned about an erosion of Medicare because, while Brownback and these eight other states really want to take over control of Medicare, Brownback have no plans on cutting the programs. Of course, if there’s recession in the future it doesn’t sound like Kansas will have a choice in cutting back Medicare, but we should probably ignore that for Sam’s sake. No, there should be no concern that the party that has made the demonization of the poor an ideological necessity (because otherwise “the market” can’t be the answer to all of life’s problems) might have secret plans in mind for gutting programs for the poor once they have the power to do so.

Parallel Strategies lobbyist David Kensinger, left, and partner Riley Scott, right, huddle in the Capitol during the 2014 legislative session with clients Mary Sloan and Ben Jones, who are with the Coalition Against the Death Penalty. The FBI is looking into Parallel Strategies.

By Tim Carpenter
timothy.carpenter@cjonline.com

The Federal Bureau of Investigation is exploring whether confidantes of Gov. Sam Brownback operated influence-peddling operations in Kansas pivoting on personal access to the Republican governor and top administration officials.

The Topeka Capital-Journal learned the months-long inquiry involves Parallel Strategies, a rapidly expanding Topeka consulting and lobbying firm created in 2013 by a trio of veteran Brownback employees who left government service to work in an environment where coziness with former colleagues could pay dividends.

Of concern to the FBI were behind-the-scenes financial arrangements related to Brownback’s privatization of the state’s $3 billion Medicaid program. The governor’s branding of KanCare handed to three for-profit insurance companies exclusive contracts to provide Medicaid services to 380,000 of Kansas’ disabled and poor.

Owners of Parallel Strategies, who also maintain separate individual lobbying firms, declined requests to discuss for this story emergence of their influential joint franchise, which includes on its client list the governor himself.

Parallel Strategies was founded by David Kensinger, Brownback’s former chief of staff and campaign manager and current director of the governor’s political organization Road Map Solutions; George Stafford, a longtime fundraiser, employee and adviser to Brownback; and Riley Scott, a senior staff member to Brownback while he was in the U.S. Senate and son-in-law of Kansas Senate President Susan Wagle, R-Wichita.

“Thanks for reaching out,” Scott said, “but I’m not interested.”

The FBI also has looked into activities of individual legislators and lobbyists unaffiliated with Parallel Strategies.

KanCare, launched in January 2013 and expanded in February, is arguably the most far-reaching reform of Brownback’s first term.

Kensinger was the governor’s chief of staff during formative construction of KanCare, but quit two months before contracts were signed with AmeriGroup Kansas, United Healthcare of the Midwest and Sunflower State Health Plan, a subsidiary of Centene. These contractors now employ as lobbyists one of Kensinger’s partners at Parallel Strategies, Kensinger’s former lobbying partner and a one-time Brownback deputy Cabinet secretary.

Questions center on whether Brownback representatives pressed companies or organizations to hire specific lobbying firms or whether entities that showed inadequate deference were targeted for political or financial punishment.
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Make a note of this because it’s a key element of what the FBI appears to be focusing on: Brownback’s chief of staff during the “KanCare” overhaul, David Kensinger, quit two months before the contracts where signed related to the privatization of Kansas’ Medicaid program (the one Brownback doesn’t want to expand). And the three organizations that got that contract now employ, as lobbyists, three partners from Kensinger’s firm Parallel Strategies.

So that’s what the FBI is investigating. Well that and the K-Street-style form of retribution-based politics that Brownback brought to Kansas. More on that below.

Continuing…

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Eileen Hawley, spokeswoman for Brownback, said she was unaware of an investigation by law enforcement involving Statehouse insiders. She asserted Brownback wouldn’t engage in unethical behavior as the state’s top elected official.

“He’s really one of the most honorable and ethical people I’ve met,” Hawley said. “I have a hard time believing any of these things were occurring in the governor’s office.”

It is unclear how far the federal investigation has progressed or whether evidence will materialize to warrant proceeding to court.

Joel Sealer, special agent with the FBI in Kansas City, Mo., said the agency’s long-standing policy was to decline public comment on topics of inquiries and targets of probes.

The election of Brownback in 2010 triggered realignment of Topeka’s political apparatus following eight years under Democratic Govs. Kathleen Sebelius and Mark Parkinson. Election night successes by conservative Republicans, according to one former Kansas GOP official, fueled an operational philosophy best captured by the phrase “to the victor belong the spoils.”

In 2012, Brownback’s red-state overhaul entered an advanced phase when he took a prominent role in a series of contested Republican Senate primary races. In a maneuver rare by Kansas standards, Brownback embraced a slate of GOP challengers and worked against incumbent Republicans opposed to pieces of the governor’s agenda. Ten Republicans seeking re-election were ousted.

“They’re ruthless,” said Steve Morris, a former Senate president who lost re-election to a GOP candidate backed by the Brownback machinery. “I served with (Govs.) Joan Finney, Bill Graves, Kathleen Sebelius and Mark Parkinson. None of them, to my knowledge, did that.”

Within days of the August primary, high-ranking members of the Brownback administration began informing political advocates that campaign contributions to moderates or Democrats would no longer be tolerated.

This message of financial loyalty was delivered in advance of a September fundraiser in Topeka headlined by Brownback. With the House already controlled by conservatives, the objective was to raise sufficient cash to elect 14 GOP candidates capable of bringing the Senate in line with the administration’s ideals. Lobbying firms were urged to demonstrate dedication to the cause by donating $500 to $1,000 to each highlighted general election campaign.

Political evolution in Topeka has been described during interviews with more than two dozen Republican, independent or Democratic lobbyists and political figures — most conducted on condition of anonymity due to their anxiety about possible retribution from allies of Brownback — as analogous to the infamous K Street in Washington, D.C.

This road-to-riches boulevard in the U.S. capital was a hub of activity among former government employees eager to exploit revolving-door access and Republicans in government who made it known they were in charge and expected future political investment to mirror that reality.
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“That is the sinister part of the Brownback folks,” said Rep. Jim Ward, a Wichita Democrat. “They punish. They can make it very cold for you. I think that’s bad for democracy. At some point, it’s going to blow up.”

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KanCare links

As it relates to KanCare, the three Medicaid contractors reinforced their lobbying operations by hiring individuals who are no strangers to Brownback.

Scott, a partner in Parallel Strategies, was added in January by United Healthcare. Gary Haulmark, a former deputy Cabinet secretary in the Brownback administration, resigned from state government in 2013 to represent Amerigroup. Sunflower employs Hickam, who ran a lobbying firm with Kensinger from 2004 to 2010.

“I believe it is wrong for people as closely connected to the seat of power to be in a position of lobbying for pay,” said former Sen. Dick Kelsey, a Republican who represented a district south of Wichita. “I still have a problem with the pay-to-play concept.”

Kelsey said Brownback officials had a political interest in tamping down complaints about KanCare until after the November election. There is an aggressive behind-the-scene campaign to minimize public criticism about denying access to treatments, placing administrative hurdles on providers delivering care, and to delaying payment of contractors.

At the same time, Kelsey said, the managed care organizations want to please the administration by hiring Brownback associates. It is a symbiotic relationship, Kelsey said, that hasn’t best served interests of clients.

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Sen. Laura Kelly, D-Topeka, said enough uncertainty about the direction of KanCare existed to warrant a significant inquiry by the Legislature. She said producing an accurate assessment would require assurances that individuals and organizations coming forward wouldn’t be subject to retaliation for speaking out.

Kelly, who serves with Crum on the KanCare oversight committee, said the model for the Legislature could be the inquiry of the Kansas Bioscience Authority led in 2011 and 2012 by Wichita Sen. Wagle, who since then was elected Senate president. The KBA, a state-financed economic development entity working to expand agriculture, animal health and human health innovation, was the subject of a legislative review and a forensic audit that cost nearly $1 million.

“If the situation at the Bioscience Authority warranted an investigation, this situation does, too,” Kelly said.

Price of dissent

Individuals who have expressed criticism about KanCare said they were targeted by Republicans representing the legislative or executive branches of state government.

Rocky Nichols, executive director of the Disability Rights Center of Kansas, a nonprofit legal advocacy organization, was publicly rebuked in March by Angela de Rocha, spokeswoman for the state’s aging and disability services agency. The Disability Rights Center has for years criticized as inadequate the funding directed at disabled Kansans.

De Rocha said the Disability Rights Center haphazardly added people to disability service waiting lists in the past “without much attention to accuracy or detail in order to provide a soapbox” useful for Nichols to “score cheap political points.”

In response, Nichols said the Disability Rights Center has no role in adding people to the waiting list. Nichols said the outburst by de Rocha indicated a willingness to attach unsavory motives to the work of an organization attempting to advance public policy under the KanCare banner. Other nonprofit groups have experienced a similar backlash for speaking out, he said.

“We have heard from several advocates and providers that if you advocate and tell the truth — if the truth is unflattering to state government — often there’s some form of blowback,” Nichols said.

Ted Cruz’s Principled Death Sentence For America Health Care Compact
But what exactly is this “Health Care Compact” that appears to open the door for some rather aggressive privatizations of Medicare too. Well, it’s an idea that’s been considered by a growing number of states in recent years as part of the national outbreak of Obamacare Derangement Syndrome:

Ohio is one of 21 states that have introduced legislation to control its health care, which includes controlling federal dollars and changes that could affect health care in the state.

Legislation would allow states to join a federally created health care compact that would transfer the authority and responsibility to make health care decisions from federal control to the member states. So far, only North Dakota has failed to pass legislation through its statehouse to join, and three states — Arizona, Minnesota and Montana — have had their governors veto legislation. There are eight states with legislation approved by their governors, and Ohio is one of eight states with legislation still pending.
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Recall that those eight states that have approved the legislation now includes Kansas, so it’s nine states so far.

Continuing…

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Republican Reps. Terry Boose, of Norwalk, and Wes Retherford, of Hamilton, introduced House Bill 227 this past June, which would allow Ohio to be a member of the health care compact. The bill passed out of the State and Local Government Committee on April 2 by way of a 10-8 vote. The vote was down party lines, though Republican Bob Hackett, of London, voted with the Democrats. Committee member Rep. Matt Lundy, D-Elyria, said this bill is not right for Ohio.

“The proposal is so extreme and has such a negative impact on the health of our citizens that even Arizona Gov. Jan Brewer vetoed (a similar bill),” said Lundy. Arizona’s state legislature passed its version of the health care compact bill in 2011, but it was vetoed by the controversial governor who became criticized in the national media for signing Arizona Senate Bill 1070, known as the “show me your papers” law. The U.S. Supreme Court in June 2012 struck down key provisions of SB 1070 but upheld a provision that allows police to check a person’s immigration status in certain circumstances.

The governors in Montana and Minnesota exercised pocket vetoes by never signing the bills that passed each of their respective state’s legislatures.

Meredith Tucker, Ohio Democratic Party communications director, called the bill a “partisan stunt.”

“It’s sad that Ohio Republicans continue these partisan stunts when there are so many important issues facing struggling Ohio families,” she said.

U.S. Rep. James Lankford, R-Oklahoma, introduced House Joint Resolution 110 in February and has garnered support from 11 Republican congressmen, including Urbana Rep. Jim Jordan, who have signed on as co-sponsors. The Oklahoma Republican said this resolution is “a breakthrough governance reform that allows states to clean up the health care mess created by the federal government.”

“Those member states are then free to implement their own health care systems without interference from federal bureaucrats, using federal health care funds already collected and spent in their state,” Lankford said.

Because of their displeasure with the Affordable Care Act, commonly referred to as Obamacare, Retherford said he and several Ohio legislators felt it necessary to work to join the health care compact efforts. And besides that, he said health care is “an issue that should be taken care at the state level.”

“Washington, D.C., often has a one-size-fits-all approach but what works for California often doesn’t work for Ohio,” said Retherford.

Ohio’s bill is likely to be presented for a vote after the May 6 primary election, Retherford said.

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As the House Republicans continue efforts to repeal the Affordable Care Act, the health care compact resolution could be part of the efforts.

“The president’s health care law continues to wreak havoc on families, local small businesses and our economy,” said Speaker of the House John Boehner. “The truth is you can’t fix this law — it needs to be torn out by its roots. Republican leadership will continue our work to replace this fundamentally flawed law with patient-centered solutions focused on lowering health care costs and protecting jobs.”

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Lankford, who opposes the Affordable Care Act, said the compact does not conflict with efforts by state attorneys general, state legislators or members of Congress to repeal or modify the health care law.

“While we wait for this president and Senate Democrats to move beyond their intransigent support of this unworkable law, Congress can give interested states a way to solve their state’s health-care problems themselves,” Lankford said. “States that like their Obamacare can keep their Obamacare. The health care compact simply gives a state like Oklahoma the option to create a customized system that better meets the needs of Oklahoma families.”

As we can see in Ohio, the “Health Care Compact” appears to largely be part of the broader effort to gut Obamacare. Yes, if Obamacare can’t be reversed at a federal level, the Compact will allow states to simply ignore the law and ALSO take control of Medicare and Medicaid (for a thorough gutting).

And if this strategy leaves states with substantially less revenue for those programs in the future that’s fine too according to the GOP. Yep! And it’s been fine since at least 2011 because there are principles behind the initiative that the GOP is trying to uphold. They’re Ted Cruz’s “Tenther” principles, and nullification of health care is just one element of a much larger struggle to nullify progress:

Kaiser Health NewsSome States Seeking Health Care Compact

By Guy Gugliotta

Sep 18, 2011

This story was produced in collaboration with The Washington Post

State governors and legislators opposed to the federal health-care law are eyeing a novel approach to escape its provisions: joining an “interstate compact” that would replace federal programs — including Medicare and Medicaid — with block grants to the states.

To date, legislation has been drafted or introduced in 14 states and brought to the floor by lawmakers in at least nine. Three Republican governors — in Georgia, Oklahoma and Texas — have signed the compact into law, while Missouri Gov. Jay Nixon (D) let the compact become law without signing it. Supporters say they hope to get 40 states to put it on the legislative calendar in 2012.

If a significant number of states pass the compact, supporters plan to submit it to Congress for approval in the same way that the body approves interstate compacts regulating commerce, transportation, and resource conservation and development.

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States have never sought a compact to shield them from a whole area of federal law, let alone been granted permission to form one. Some state officials, including Republicans such as Arizona Gov. Jan Brewer who vetoed the compact, are worried that it would usurp their authority. Many others point out that joining a compact would disqualify their states from receiving automatic federal funding increases during hard times and prevent them from getting their fair share of the available pool of money.

Still, even if its prospects are more dubious than other methods of getting rid of last year’s Patient Protection and Affordable Care Act — congressional repeal, judicial challenge or a Republican presidential victory in 2012 — the compact has become a popular way for conservatives to highlight their opposition.

And compacts might receive even more attention now that Texas Gov. Rick Perry signed his state’s law July 18, just three weeks before he announced his candidacy for the Republican presidential nomination. The primacy of states’ rights over federal powers is a tenet of tea party Republicans whose support is key for candidates during the primary season.

For the original drafters, health care is only the first compact in a longer list that would include measures giving states broad powers to control banking, education and energy. “Our view is that a good policy made under bad governance will morph into bad policy,” said Houston businessman Leo Linbeck III, a key financial backer of the compact initiative. “Progress doesn’t mean centralizing power. Progress pushes decision-making power back to the people.”
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The health-care compact grew out of discussions and research conducted a year ago at the Center for Tenth Amendment Studies at the Austin-based Texas Public Policy Foundation, a conservative policy group. The 10th Amendment to the Constitution leaves to the states all powers not conferred upon the federal government.

“Founding Fathers like James Madison sold the Constitution to the individual states by predicting that the accumulation of federal power would never happen because the states were too strong,” said Mario Loyola, director of the Tenth Amendment Center. “The federal government now regulates virtually all of the things the framers said it would never regulate.”

Looking around for tools to reverse this trend, Loyola, a former counsel for the U.S. Senate’s Republican Policy Committee, and former Texas Solicitor General Ted Cruz, now a candidate for the U.S. Senate, hit upon the interstate compact, which Loyola said “held the promise of reestablishing a boundary between state and federal authority through a consensual agreement with Congress.”
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Again, note that Ted Cruz was one of the originators of the Compact. Ted Cruz.

Continuing…

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The history of compacts goes back to the colonial period, and more than 200 are currently in force. Many coordinate activities between contiguous states, such as the Port Authority of New York and New Jersey. Others, such as the Driver License Compact and the Wildlife Violators Compact, offer reciprocal recognition of laws and licenses in member states.

The Health Care Compact, however, is the first one that attempts to shield states from a whole area of federal law. It is four pages long and would replace the current federal health-care system with block grants to the states. The initial grants would be pro-rated on the basis of 2010 federal funding levels. Thereafter, allocations would rise to reflect inflation and state population increases. The compact would not apply to military personnel, veterans or Native Americans.

With this template in hand, the bill’s adherents formed the Health Care Compact Alliance late last year. Eric O’Keefe, chairman and chief executive of the conservative Sam Adams Alliance, is the Compact Alliance chairman, and Linbeck serves as vice chairman. O’Keefe said the Alliance has so far spent “not much more” than $1 million.

Late in 2010, O’Keefe won support for the compact from leaders of the Tea Party Patriots, one of the main tea party groups that have emerged across the country. Linbeck said “our big push” will come in early 2012, when he and O’Keefe are hoping that 25 to 40 legislatures may take up the bill. O’Keefe said he would prefer to have at least 15 states pass the compact before it is sent to Congress.

In its early days, critics denounced the measure as a reprise of the 19th century doctrine of “nullification,” holding that any state could ignore a federal law it did not like. Linbeck pointed out, however, that the Health Care Compact is not nullification, since it requires congressional consent.
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Recall that “nullification” of federal law has been one of the GOP’s primary meta-themes in recent years, so while this Health Care Compact may have sounded pretty “out there” back in 2011 when this was first proposed, times have changed (somewhat) for the GOP! Sometimes it even includes nullifying local laws. That’s how much the GOP loves nullification these days (hint: that’s because it’s mostly about nullifying opposition to the oligarchs).

Continuing…

…Drawbacks For States

Signing on has drawbacks for states. The compact cannot be amended unless all participating states agree to the amendment and resubmit the bill to their legislatures. For elected officials who want to put their stamp on their state’s laws, this can be a hard pill to swallow.

Also, if states were underfunded in 2010 at the federal level, they would be stuck there under the compact. “We have 3 million people in Medicare and another 4 million on Medicaid and CHIP (the Children’s Health Insurance Program),” said Anne Dunkelberg, associate director of the Austin-based Center for Public Policy Priorities, a think tank focusing on low- and moderate-income Texans. “Just now [in Texas] we’re $600 below the national average per person for Medicaid.”

And, Dunkelberg added, adherence to the compact would eliminate the guarantee of a federal match to state Medicaid spending, make a state ineligible for one-time entitlements such as the 2009 stimulus and cause states to lose access to automatic increases when enrollment goes up during a recession.
…

Did you see that last part? The Compact would cause states “to lose access to automatic increases when enrollment goes up during a recession” (see the fixed nature of the “Funding” section of the Compact). And if it turns out that this was a horrible idea, good luck amending it since you’d need all the members to approve! That’s just part of the anti-Obamacare fun on display with this Healthcare Compact idea and with Kansas signing on as the ninth state that idea could potentially become a reality, especially if the GOP takes control of the Senate this year.

So, putting aside Governor Brownback’s recent FBI investigations into Kansas’ Medicaid privatization schemes, isn’t it somewhat fascinating that we haven’t seen more of a unified strategy from the GOP in promoting the Compact on the national campaign trail? It’s an election year and opposition to Obamacare is still a central component of the GOP’s national electoral strategy. Plus, it’s very much in keeping with the “States Rights” theme the GOP has been pushing ever since Obama first took office. So why isn’t the Compact a bigger “theme” this year? Is it just bad timing?

Or could it be that the GOP’s lacks faith in the electorate? Don’t forget, the Health Care Compact proposal that Sam Brownback just signed requires Kansans to believe that people like Brownback won’t stab them in the back while gutting their Medicare. Is that a realistic hope? After all, opposition to Obamacare is relatively easy. You just have to say “I don’t like this or that about the program”, and people you’ll find plenty of people to agree with you. But, as many have pointed out, the GOP hasn’t really put forth any alternatives to Obamacare so far and that’s where the electorate’s faith in the GOP gets tests. And yet, there IS a GOP alternative to Obamacare: The Health Care Compact! It was even the brainchild of the GOP’s id!

Could the GOP be losing the “don’t worry, we won’t hurt you” credibility it needs to “sell” its plans to gut Medicare without alarming seniors? Championing the Health Care Compact on the campaign trail sure would raise some alarming questions in the voting booth for seniors. Could that explain the lack of enthusiasm for making this a national party platform? For example, if politicians and the oligarchs that fund them are trying to grabgreen eggs and hamand healthcare from those with the least, and then these same politicians start campaigning about sending Medicare powers back to the very same states with governors that are trying to gut Medicaid, doesn’t that raise the question of what else their hearts desire? Maybe that’s a question the GOP would rather not have to answer.

Discussion

Here’s some good new for Oklahoma residents: Oklahoma is finally accepting the federal Medicaid expansion funds in order to cover a gaping budget deficit that threatens to shut down the state’s healthcare system. It’s also good news for ardent opponents of Obamacare who are willing to jump through whatever mental hoops are necessary to tell themselves that they aren’t actually engaged in a Medicaid expansion because that would somehow be giving in to the Big Bad Obama. Everyone’s a winner:

Dwight Sublett has seen a lot of busts in his 33 years as a pediatrician in Stillwater, Oklahoma, but this year ranks among the worst. With oil hovering at $35 a barrel, the state is facing a $1.3 billion budget shortfall for the fiscal year starting on July 1. On March 29 the Oklahoma Health Care Authority warned it would have to cut 25 percent from reimbursements to physicians, hospitals, and other medical providers under the state’s Medicaid program, SoonerCare. The program covers a million poor Oklahomans each year, more than a quarter of the state’s population. “For the rural physicians, this is going to be a devastating blow,” Sublett says.

Across the country, Medicaid covers 71 million low-income Americans. Medicaid is jointly funded by the federal government and states, and it typically accounts for 20 percent to 35 percent of a state’s annual budget. The crash in oil prices has made it harder for energy-dependent states to come up with their share. “These states that have had fairly stable budgets—Oklahoma would be the classic example—suddenly they’re running really big deficits,” says Gregory Hagood, senior managing director of Solic Capital, an investment and advisory firm that works with hospitals in financial distress.

Oklahoma has declined to expand Medicaid, leaving uninsured an estimated 91,000 people who might have qualified for federally subsidized coverage under the 2010 Affordable Care Act. “You mention ‘Medicaid expansion,’ that’s dirty words in this state” because of the link to Obamacare, Sublett says. About 16 percent of Oklahomans had no health insurance in 2014, compared with 10 percent of the national population, according to the Kaiser Family Foundation.

Years of tax cuts in Oklahoma have contributed to the budget hole. The top state income tax rate declined from 6.65 percent in 2004 to 5 percent this year, eliminating $1 billion in annual revenue, according to the nonprofit Oklahoma Policy Institute. Tax revenue will come in about 7 percent below the level expected for the budget year ending on June 30, says Nico Gomez, chief executive officer of the Oklahoma Health Care Authority, which oversees Medicaid. He’s preparing for a 15 percent cut in state funding next year, though the precise amount is uncertain. For every 40¢ the state cuts from Medicaid, Oklahoma loses 60¢ in federal matching funds.

…

Gomez has proposed what he calls a long-term solution. Under his plan, about 350,000 Oklahomans who are on Medicaid or uninsured would get subsidized insurance through a state program, Insure Oklahoma, that predates the Affordable Care Act and is mostly funded by tobacco taxes. The change would require approval from administrators in Washington to free up an infusion of federal Medicaid funds.

The proposal is broadly similar to backdoor arrangements several Republican-led states, including Arkansas and Indiana, have used to get federal funds for expanding health coverage with private insurance rather than Medicaid. Gomez is quick to note that his proposal would shrink the Medicaid rolls in his state. “We’re not actually growing the entitlement,” he says.

Health-care providers in Oklahoma would welcome the move, whatever it’s called. “We don’t seem to have a problem in this state in accepting federal dollars for roads or other purposes,” says Craig Jones, president of the Oklahoma Hospital Association, which has pushed the state to take advantage of federal money available under the Affordable Care Act. “It’s only because it’s tied to Obamacare that people have had a real concern about it.”

“The proposal is broadly similar to backdoor arrangements several Republican-led states, including Arkansas and Indiana, have used to get federal funds for expanding health coverage with private insurance rather than Medicaid. Gomez is quick to note that his proposal would shrink the Medicaid rolls in his state. “We’re not actually growing the entitlement,” he says.”
Sure, sure, no expanded entitlement program at all. Just say whatever is necessary in order to provide the political cover required to implement a big new expansion of health insurance coverage so Oklahoma can get its hands on those billions in federal Medicaid expansion funds and prevent an implosion of its medical system:

Associated Press

In surprising turnabout, Oklahoma eyes Medicaid expansion

By SEAN MURPHY
May. 16, 2016 8:43 AM EDT

OKLAHOMA CITY (AP) — Despite bitter resistance in Oklahoma for years to President Barack Obama’s health care overhaul, Republican leaders in this conservative state are now confronting something that alarms them even more: a huge $1.3 billion hole in the budget that threatens to do widespread damage to the state’s health care system.

So, in what would be the grandest about-face among rightward leaning states, Oklahoma is now moving toward a plan to expand its Medicaid program to bring in billions of federal dollars from Obama’s new health care system.

What’s more, GOP leaders are considering a tax hike to cover the state’s share of the costs.

“We’re to the point where the provider rates are going to be cut so much that providers won’t be able to survive, particularly the nursing homes,” said Republican state Rep. Doug Cox, referring to possible cuts in state funds for indigent care that could cause some hospitals and nursing homes to close.

Despite furious opposition by conservative groups, Republican Gov. Mary Fallin and some GOP legislative leaders are pushing the plan, and support appears to be growing in the overwhelmingly Republican Legislature. Details have not been ironed out but the proposal is based on an Indiana program that received federal approval.

…

A bust in the oil patch has decimated state revenues, compounded by years of income tax cuts and growing corporate subsidies intended to make the state more business-friendly.

Oklahoma’s Medicaid agency has warned doctors and other health care providers of cuts of up to 25 percent in what the state pays under Medicaid.

“We are nearing a colossal collapse of our health care system in Oklahoma,” warned Craig Jones, the president of the Oklahoma Hospital Association, which represents more than 135 hospitals and health care systems in the state. “We have doctors turning away patients. We have people with mental illnesses who are going without treatment. Hospitals are closing, and this is only going to get worse this summer if the Legislature does not act immediately to turn this around.”

In the poverty-wracked southeastern corner of the state, where 96 percent of babies in the McCurtain Memorial Hospital are born to Medicaid patients, most health care would end, said hospital CEO Jahni Tapley.

“A 25 percent cut to Medicaid would not put my hospital in jeopardy, because we are already in jeopardy,” Tapley said. “A 25 percent cut would shutter our doors for good, leaving 33,000 people without access to health care.”

Nursing homes have been warning residents that they may be closing. Asked where she would go if the Beadles Nursing Home in the small town of Alva closes, Jeanie Yohn, 89, said: “I just can’t imagine. I have three daughters, but they don’t live here.”

Under the proposal, which would be funded in part with a $1.50-per-pack tax on cigarettes, Oklahoma would shift 175,000 people from its Medicaid rolls onto the federal health exchange created by the Affordable Care Act. That would make room for adding to Medicaid roughly the same number of working poor who are currently uninsured. Participants would pay nominal premiums and co-pays.

The move, by increasing the number of uninsured people covered, would allow the state to tap into the extra money offered under the federal law. Beginning in 2017, the federal government would cover 95 percent of the state’s Medicaid costs, decreasing to 90 percent of the share in 2020.

No matter what state leaders call it, conservative groups aren’t happy about the idea of more government health spending.

“They can call it Medicaid rebalancing, but there’s only one federal program that offers a 9-to-1 federal match, and that’s Obamacare,” said Johnathan Small, president of Oklahoma Council on Public Affairs, a free-market think-tank that opposes higher taxes. The opponents have called for covering health costs by cutting spending for less essential programs.

Americans for Prosperity, another conservative think-tank backed by the billionaire philanthropist Koch brothers, David and Charles, also has launched a campaign against the proposal and is hosting a “NobamaCare” event at the state Capitol to voice their opposition.

“Fallin, a former congresswoman who voted against Obama’s health plan when it came before the House, argues that the plan doesn’t amount to expanding Medicaid because the program’s rolls don’t grow. Rather, she said, it “transitions 175,000 Medicaid enrollees to the private insurance market.””
Uh huh. This isn’t like Obamacare at all. It’s “Medicaid rebalancing”:

…
“They can call it Medicaid rebalancing, but there’s only one federal program that offers a 9-to-1 federal match, and that’s Obamacare,” said Johnathan Small, president of Oklahoma Council on Public Affairs, a free-market think-tank that opposes higher taxes. The opponents have called for covering health costs by cutting spending for less essential programs.
…

Just remember: It’s a “Medicaid rebalancing” scheme that just happens to involve accepting the federal government’s 9-to-1 matching funds that states like Oklahoma have been rejecting all along. Make sure no one uses the term “Medicaid expansion,” because Oklahoma’s lawmakers might become ashamed enough of their Obamacare acceptance that they go back to shamelessly letting their constituents die. And that would be a shame. And sort of manslaughter.

When you think about the arch of the Obamacare roll out, from the 110 percent opposition from the GOP to the Supreme Court’s 2012 ruling that made Medicaid expansion optional and a political football, it’s easy to forget what the following article from the summer of 2012 reminds us, which is that not only did most Americans support the bulk of Obamacare back then.

Republicans support Obama’s health reforms — as long as his name isn’t on them

By Greg Sargent June 25, 2012

The new Reuters-Ipsos poll finds that Obamacare remains deeply unpopular; 56 percent of Americans oppose the law, versus only 44 percent who favor it. The poll also finds that strong majorities of Americans favor the individual provisions in the law — the hated individual mandate excepted, of course.

What’s particularly interesting about this poll is that solid majorities of Republicans favor most of the law’s main provisions, too..

…

* Eighty percent of Republicans favor “creating an insurance pool where small businesses and uninsured have access to insurance exchanges to take advantage of large group pricing benefits.” That’s backed by 75 percent of independents.

* Fifty-seven percent of Republicans support “providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.” That’s backed by 67 percent of independents.

* Fifty-four percent of Republicans favor “requiring companies with more than 50 employees to provide insurance for their employers.” That’s backed by 75 percent of independents.

* Fifty two percent of Republicans favor “allowing children to stay on parents insurance until age 26.” That’s backed by 69 percent of independents.

* Seventy eight percent of Republicans support “banning insurance companies from denying coverage for pre-existing conditions; 86 percent of Republicans favor “banning insurance companies from cancelling policies because a person becomes ill.” Those are backed by 82 percent of independents and 87 percent of independents.

* One provision that isn’t backed by a majority of Republicans: The one “expanding Medicaid to families with incomes less than $30,000 per year.”

“Most Republicans want to have good health coverage,” Ipsos research director Chris Jackson tells me. “They just don’t necessarily like what it is Obama is doing.”

I’d add that Republicans and independents favor regulation of the health insurance system in big numbers. But the law has become so defined by the individual mandate — not to mention Obama himself — that public sentiment on the reforms themselves has been entirely drowned out. It’s another sign of the conservative messaging triumph in this fight and the failure of Dems to make the case for the law. And it suggests that if the law is struck down, Dems might be able to salvage at least something from the wreckage by refocusing the debate on the idividual reforms they’ve been championing — and what Republicans would replace them with, if anything.

“I’d add that Republicans and independents favor regulation of the health insurance system in big numbers. But the law has become so defined by the individual mandate — not to mention Obama himself — that public sentiment on the reforms themselves has been entirely drowned out. It’s another sign of the conservative messaging triumph in this fight and the failure of Dems to make the case for the law. And it suggests that if the law is struck down, Dems might be able to salvage at least something from the wreckage by refocusing the debate on the individual reforms they’ve been championing — and what Republicans would replace them with, if anything.”
Yes, when a majority of Americans oppose a big new reform package that can dramatically dramatically help millions, and that opposition is largely due to for lies, hype, and an apparent mass lack of awareness of how the reforms actually worked, it’s a safe bet that there’s been another conservative messaging triumph.
But when it’s a life and death issue like healthcare access, it might not be a permanent messaging triumph. At least when it comes to the Medicaid expansion. At least in Texas:

More than 60 percent of Texans support an expansion of Medicaid here and plan to take those views into the voting booth in November, a new survey commissioned by the Texas Medical Center Health Policy Institute finds.

The survey results, unveiled Wednesday at the annual Medical World Americas convention in Houston, show the public at odds with the state’s Republican leadership, which has steadfastly refused to consider such an expansion, calling it wasteful and a bad solution.

“I understand people in Austin have been reluctant, but I believe what this survey demonstrates is that people want something done to improve access,” said Dr. Arthur “Tim” Garson, director of the Health Policy Institute. “People are looking for help and their choice seems to be Medicaid expansion. A uniquely Texas solution would be best, but we have to do something.”

The findings further resonate in a state that continues to lead the nation in the number of uninsured. Texas remains one of 19 states that has chosen not to expand Medicaid under the Affordable Care Act.

The second annual Medical Center study gauging public opinion on health care issues covered topics ranging from access to health care to the wisdom of raising the price of foods that contribute to obesity.

Of the 1,000 people polled by Nielsen in five states, close to 100 percent said they feel it is deeply important to have insurance for themselves and their family. In Texas, 96 percent value health insurance.

The study’s margin of error is 3 percentage points overall and close to 5 percentage points in Texas.

Beyond self-interest, 91 percent of respondents in Texas, California, New York, Ohio and Florida said it was important to them that everyone in the nation have health insurance.

The sticking point has always been how to get there.

In Texas, 63 percent of those polled said they support an expanded Medicaid program. Similarly, 68 percent in Florida also favored a Medicaid expansion. These numbers are significant because of the states surveyed, only Florida and Texas did not expand the safety-net program, which is jointly paid for with federal and state dollars.

…

Seeking more flexibility

On Wednesday night, the head of the conservative Texas Public Policy Foundation said she remains unmoved.

“Though we haven’t yet seen the study, no study will change the fact that Medicaid is a program that provides a very low quality of care at a very high cost to taxpayers,” executive director Arlene Wohlgemuth said in a statement.

“The federal requirements that come with Medicaid expansion make it the wrong way to address the unique health care needs of Texans. Instead, states must be given the flexibility to create a program that better serves Texans in need, and one that works with communities to design programs that work for them and for taxpayers.”

Health care costs and access also are part of the national political debate. On the Republican side, presumptive nominee Donald Trump is echoing calls to dismantle the Affordable Care Act altogether, although he previously said he favored the mandate that required everyone to carry health coverage.

Among Democrats, front-runner Hillary Clinton has said she would continue the federal health care law and expand it. Her rival Sen. Bernie Sanders has proposed universal health care, saying coverage is a right not a privilege.

In the five states surveyed for the Health Policy Institute, respondents were emphatic that a political candidate’s stance on health issues will influence how they vote, a sentiment shared by 82 percent of Texans.

…

Despite widely differing demographics, both red and blue politically, and with and without Medicaid expansion, opinions in the surveyed states remained mostly consistent.

“What I found interesting was not how different people were but how much they were the same,” Garson said.

“In Texas, 63 percent of those polled said they support an expanded Medicaid program. Similarly, 68 percent in Florida also favored a Medicaid expansion. These numbers are significant because of the states surveyed, only Florida and Texas did not expand the safety-net program, which is jointly paid for with federal and state dollars.”
Well, it would appear that a majority of the electorate, including the red state electorates that vote in state governments that oppose the Obamacare Medicaid expansion, wants the full Obamacare program in place including the Medicaid expansion. Except maybe no the individual mandate. But if there is still strong opposition to the individual mandate, poll results like:

…
Beyond self-interest, 91 percent of respondents in Texas, California, New York, Ohio and Florida said it was important to them that everyone in the nation have health insurance.
…

make it hard to see where exactly the opposition is coming from.

So it appears that voters in Texas and elsewhere without Obamacare are increasingly less swayed by the argument that they should be turning away billions of dollars in free federal healthcare money that most other states are taking in order to keep the federal debt down a little bit. Sure, turning down those billions of dollars in federal healthcare dollars is a great way to for politicians to show they’re willing to walk the talk. But it also involves generally financially undermining the state. And letting people die. Which is why it’s not particularly surprising a strong majority of Texans want their Medicaid expanded.

That’s also why it’s not particularly surprising that Georgia’s GOP is looking into no longer allowing so many Georgians to needlessly die for a political posture. Looking into it grudgingly:

Modern Healthcare

Georgia eyes Medicaid expansion

By Virgil Dickson | May 18, 2016

In an effort to better provide healthcare to Georgia’s exploding population and as a way to balance the state’s budget, conservative lawmakers are renewing temporary Medicaid payment increases and looking at expanding the program, according to a Republican state Senate leader.

Sen. Renee Unterman, chairwoman of the Senate’s Health and Human Services Committee, said that while she’s been critical of Medicaid expansion, she’s seeing hospitals close and people waiting to see providers.

Unterman said there is enough support in the Senate for a conservative expansion model, similar to the one in place in Arkansas. Under that state’s model, residents with incomes between 100% and 138% pay up to 2% of their income in monthly premiums.

The Georgia Chamber of Commerce is expected to present some expansion ideas to the General Assembly when it reconvenes in January 2017, she said.

State Rep. Sharon Cooper, the Republican chairwoman of the House’s Health and Human Services Committee, said she and her colleagues will entertain the proposals, but added that she doesn’t believe it will solve the access problem.

“The problem with expansion is, who is going to treat these people,” Cooper said. “We don’t have the physicians, nurse practitioners or physician assistants to care for them in rural areas of the state.”

Access to care is scarce in rural parts of Georgia, where five hospitals have closed since 2012, according to state data.

Unterman and other lawmakers say that access to care issues are only increasing as the state’s population explodes. A healthy job market has drawn more than a 20% population spike between 2000 and 2015. There are currently 10.2 million residents in the state, according to census data.

And as many as 400,000 people would be eligible for Medicaid expansion. An expansion could have drawn $33 billion in federal funding between 2013 to 2022, with nearly $13 billion of that going to hospitals, according to a 2014 Urban Institute report. The funding could have aided the 66% of rural hospitals that in 2014 ended the year with negative margins. In all, 41% of Georgia’s hospitals ended 2014 with negative margins, according to the Georgia Hospital Association.

Oklahoma, likewise, is now looking at an expansion to help cover a $1.3 billion budget hole that’s devastated the state’s providers.

…

“And as many as 400,000 people would be eligible for Medicaid expansion. An expansion could have drawn $33 billion in federal funding between 2013 to 2022, with nearly $13 billion of that going to hospitals, according to a 2014 Urban Institute report. The funding could have aided the 66% of rural hospitals that in 2014 ended the year with negative margins. In all, 41% of Georgia’s hospitals ended 2014 with negative margins, according to the Georgia Hospital Association.”
Ouch. Well, that Medicaid opposition was some utterly pointless political posturing that inflicting $33 billion in damage to the state’s healthcare system and people. Dropping opposition to that expansion sure sounds like the kind of reform the US healthcare system could use right now. We got Zika and stuff to worry about. It’s not the best time to keep collapsing healthcare systems on the medical worry list.

So with more and more states looking likely to expand Medicaid sooner or later, the grudging nature of Georgia’s GOP’s open mindedness to the expansion is a reminder that every state’s Medicaid expansions is going to be heavily contingent on whether or not there’s a President Trump in 2017. If President Trump happens, so long Medicaid expansion and hello untreated Zika! It’s one of the reasons it won’t be super surprising if getting solid details on how President Trump and a GOP Congress plan on replacing Obamacare and the Medicaid expansion becomes one of the biggest issues of the 2016 campaign. It’s just very timely because healthcare is always timely. And the rabble is sort of waking up.

But it also won’t be super surprising if other issues take the public focus away from questions of the GOP’s post-Obamacare vision. The competition for the the issues that will capture the attention of the 2016 election national discourse is fierce.

Now that President-elect Donald Trump and the GOP-controlled Congress are set to repeal the New Deal and replace with a new fascist social contract, one of the biggest questions remains how they will pull this off while avoiding blame for doing this that Trump pledge not the do and GOP voters have resisted for years. Things like privatizing Social Security and Medicare. It’s one of the grand perversions of the GOP: One of the GOPs primary goals as a party is to avoid all the inevitable blame it really deserves recieve for achieving the party’s policies goals. It’s one of the reasons the GOP loves it when the Democrats agree to support Republican policies out of some misguided spirit of bi-partisanship.

At the same time, given the fact that President Trump campaigned as an outsider who’s not really a Republican instead but some sort of populist, we’ve created this fascinating situation where the GOP can now achieve virtually all of its long-time policy goals and let Trump take all the blame. And while Donald Trump will certainly deserve and immense amount of blame for nightmare he’s about to unleash, he still shouldn’t get all of it. It’s one of the many bizarre tensions that will now come to dominate Washington DC: Now that the electorate effectively removed the Democrats from power, the party isn’t really able to play the traditional game of “avoiding blame for corporatist policy real-world consequences” hot-potato. But with an alleged “outsider” as the new president, that game can still transpire. It’s just an intra-GOP now and the more Trump “takes over” the GOP while essentially carrying out a the classic GOP corporatist agenda, the more he’ll end up essentially absorbing all the blame that should rightly be incurred by the rest of the GOP. And since this is a dynamic Donald Trump must realize , you have to wonder if that’s part of the reason Trump is now suggesting he might keep key elements of Obamacare:

Talking Points Memo Livewire

Trump: There Won’t Be A Gap Between Obamacare Repeal And Replacement

By Caitlin MacNeal
Published November 12, 2016, 10:58 AM EDT

In an interview on CBS News’ "60 Minutes" set to air in full on Sunday, Donald Trump said that there would not be a gap between repealing Obamacare and putting in place a replacement.

“We’re going to do it simultaneously. It’ll be just fine. That’s what I do. I do a good job. You know, I mean, I know how to do this stuff. We’re going to repeal it and replace it. And we’re not going to have, like, a two-day period and we’re not going to have a two-year period where there’s nothing,” he said. “It will be repealed and replaced. I mean, we’ll know. And it’ll be great health care for much less money.”

Trump also confirmed what he said in a Friday Wall Street Journal interview about two aspects of Obamacare he’s looking to keep in place. He does not want to eliminate the provision that keeps insurers from denying coverage to those with pre-existing conditions, and he wants to allow children to stay on their parents’ health insurance until age 26.

“Trump also confirmed what he said in a Friday Wall Street Journal interview about two aspects of Obamacare he’s looking to keep in place. He does not want to eliminate the provision that keeps insurers from denying coverage to those with pre-existing conditions, and he wants to allow children to stay on their parents’ health insurance until age 26.”

Oh look at that, Donald Trump, who made repealing and replacing Obamacare one of his campaign rallying cry, now wants to keep parts of Obamacare: no denial of coverage for pre-existing conditions and allowing children to stay on their parents’ insurance until the age of 26. And it’s no mystery as to why he would want to keep them. Those are really popular provision and whoever takes them away is going to have so unhappy voters to deal with.

After reiterating his promise to repeal and replace the Affordable Care Act, President-elect Donald Trump has indicated that he may keep two of the law’s most popular provisions. One is straightforward enough — children up to the age of 26 being allowed to stay on their parents’ plan. The other — preventing insurance companies from denying coverage because of preexisting conditions — offers a perfect illustration of why Trump and most of the other Republicans critics of Obamacare don’t understand the health insurance market.

Let’s say that in the beautiful new world of “repeal and replace,” insurers are required to sell you insurance despite the fact that your kid has a brain tumor. Insurance companies know what to do with that. Their actuaries can calculate that kids with brain tumors typically require (I’m making this number up) about $200,000 a year in medical care. So they’ll offer to sell you a policy at an annual premium of $240,000.

So how do you prevent that kind of gaming of the system by consumers? Well, that’s easy. You require that everyone buy at least some minimal level of insurance at the beginning of every year, so they can’t buy insurance only after they get sick. Let’s call that an” individual mandate.” But because you can’t expect poor people to pay $1,000 a month, they will require subsidies to keep their out-of-pocket costs to something like 10 percent of income. To pay for the subsidies, a new tax will be required.

So let’s review what just happened. To guarantee that people with pre-existing conditions can get affordable health insurance, you need to have rules requiring guaranteed issue and community rating. To keep insurance companies in business because of guaranteed issue and community rating, you need to have an individual mandate. And because poor people can’t afford health insurance, you need subsidies. Combine all three, and what you have, in a nutshell, is … Obamacare.

Yes, it’s a bit more complicated than that, but not much. It’s possible to allow insurance companies charge twice or three times as much, to people who are older or sicker. You can let healthy people buy somewhat more barebones “catastrophic” policies to satisfying their obligation under the individual mandate. You could even avoid community rating by sending sick people into “high risk pools” where their premiums would be subsidized by a tax on everyone else’s health care premiums.

But at the end of the day, once you decide that everyone, regardless of age or medical condition, should be able to buy health insurance at an affordable price, you have essentially bought into the idea that young and healthy people have an obligation to subsidize the older and sicker people in some fashion. And once you do that, it’s sort of inevitable you end up where every health reform plan has ended up since the days of Richard Nixon. You end up with some variation on Obamacare.

Of course, if you want to scrap guaranteed issue, scrap community rating, scrap the individual mandate and scrap the subsidies, as Republicans, propose, then you end up where the country was in 2008—with a market system that inevitable gives way to an insurance spiral in which steadily rising premiums cause a steadily rising percentage of Americans without health insurance.

There are no easy solutions here, no free lunches. You can’t have all the good parts of an unregulated insurance market (freedom to buy what you want, when you want, with market pricing) without the bad parts (steadily rising premiums and insurance that is unaffordable for people who are old and sick).

At the same time, you can’t have all the good parts of a socialized system (universal coverage at affordable prices) without freedom-reducing mandates and regulations and large doses of subsidies from some people to other people. Anyone who says otherwise – anyone promising better quality health care at lower cost with fewer regulations and lower taxes—is peddling hokum.

“But at the end of the day, once you decide that everyone, regardless of age or medical condition, should be able to buy health insurance at an affordable price, you have essentially bought into the idea that young and healthy people have an obligation to subsidize the older and sicker people in some fashion. And once you do that, it’s sort of inevitable you end up where every health reform plan has ended up since the days of Richard Nixon. You end up with some variation on Obamacare.”

So now we get to find out if Trump’s Obamacare partial-repeal that keeps the pre-existing conditions protections will also include a commitment to ensure access to affordable insurance or instead guarantees access to unaffordable insurance for those with pre-existing conditions…

…
Let’s say that in the beautiful new world of “repeal and replace,” insurers are required to sell you insurance despite the fact that your kid has a brain tumor. Insurance companies know what to do with that. Their actuaries can calculate that kids with brain tumors typically require (I’m making this number up) about $200,000 a year in medical care. So they’ll offer to sell you a policy at an annual premium of $240,000.
…

Or maybe do what the rest of the GOP proposes, which is repeal Obamacare and replace it with the nightmare that existed before Obamacare…

…
Of course, if you want to scrap guaranteed issue, scrap community rating, scrap the individual mandate and scrap the subsidies, as Republicans, propose, then you end up where the country was in 2008—with a market system that inevitable gives way to an insurance spiral in which steadily rising premiums cause a steadily rising percentage of Americans without health insurance.
…

That’s all what Trump and the GOP get to decide on healthcare reform: Do they replace Obamacare with…Obamacare, and at least avoid all the fallout that would come with replacing Obamacare with some broken joke system. Or do they replace Obamacare with a broken joke system and blame then play “avoiding blame for corporatist policy real-world consequences” hot-potato. We’ll find out what they decide to do about Obamacare, but it’s worth noting that whatever path they end up taking will be but one of the many upcoming Trump/GOP assaults on Americans’ retirement security and safety-net:

Reuters

After U.S. election, retirement security heads for a crash

By Mark Miller | CHICAGO
Fri Nov 11, 2016 | 7:09am EST

Retirement security already looked like a looming train wreck for most U.S. households before Election Day. Now, the consolidation of Republican control of government threatens to accelerate the crash.r

It is too early to predict the agenda Donald Trump will bring to the White House on retirement policy, or where it might fit on his priority list. We live in a rapidly aging nation, but retirement policy never received a serious airing during the hot mess of a campaign that just ended.

It is also impossible to predict how Trump’s priorities will match up with those of Republican leaders in Congress, considering their deep divides on many issues during the campaign.

But previous Republican proposals and Trump’s campaign pledges point toward a range of possible GOP retirement initiatives between now and the 2018 midterm elections.

The economic frustrations of older, middle-class voters played an important role in Trump’s upset win over Hillary Clinton. Exit polling reveals that voters above age 45 favored him, especially among middle-class households.

These are households bearing the brunt of job loss, income inequality, the decline of traditional defined benefit pensions, rising healthcare costs and shrinking Social Security benefits. And they have managed to save precious little for retirement: 62 percent of working households headed by people aged 55-64 have less than one year of annual income, according to the National Institute on Retirement Security (NIRS) – far less than they will need to maintain their standard of living in retirement.

But here is the irony: Republican control of the White House and Congress over the next two years could leave these struggling near-retirement households even worse off. Below is just a partial rundown of the retirement-related issues that will bear careful watching.

OBAMACARE REPEAL

This might not seem like a retirement issue at first glance. But if Trump and Republican lawmakers make good on their promises to repeal the Affordable Care Act, millions of older Americans who fall short of Medicare’s eligibility age (65) likely will lose their health insurance.

Hate Obamacare if you like, but it has hugely benefited millions of older low- and middle-income households. The Commonwealth Fund estimates that the percentage of uninsured Americans aged 50-64 fell to 9.1 percent this year, compared with 14 percent in 2013. That translates to 3.1 million previously uninsured people who now have health insurance.

Republicans will likely try to repeal the law, or at minimum gut many of its most important provisions, such as Medicaid coverage for low-income people, and premium subsidies for middle-income households.

The uninsured-and-over-fifty group will be more likely to forego healthcare, and they will arrive at Medicare’s doorstep with more untreated illnesses.

“If they repeal it and don’t replace it with something meaningful, it’s going to really hurt this older population,” said Christian Weller, professor of public policy at the University of Massachusetts Boston.

SPIKE THE FIDUCIARY RULE

The U.S. Department of Labor finalized rules this year requiring all financial advisers working with retirement accounts to avoid conflicts and act in the best interest of clients in the products they recommend. This is a huge, positive step in reforming the way retirement savings are managed.

Trump took no position on the so-called fiduciary rule, but he has pledged to cut government regulation aggressively. And one of his advisers promised during the campaign to repeal the rule, even likening it to slavery.

…

CUT SOCIAL SECURITY AND MEDICARE

Trump said during the campaign he does not favor cutting Social Security or Medicare benefits. But Republican congressional leadership has long favored raising the Social Security retirement age, reducing cost-of-living adjustments and at least partial privatization of the program by allowing workers to divert part of their payroll tax contribution to a personal savings account.

This year’s Republican convention platform stated that Social Security’s solvency problems should be addressed without tax increases. That is a de facto call for benefit cuts, because there are only two ways to solve Social Security’s financial problems: cut benefits or increase revenue. The platform also contained a vague call for privatization.

On Medicare, House Speaker Paul Ryan has advanced plans repeatedly to shift Medicare toward so-called premium support. Seniors could choose between private insurance plans and traditional Medicare, and receive a voucher from the federal government to purchase coverage. Studies have shown this approach would shift costs to seniors.

RETIREMENT SAVING, LONG-TERM CARE

Among the other questions to ponder: How will we reform our retirement saving system to increase coverage and low-cost saving? How will we fix our broken approach to financing long-term care?

All told, the inequalities in our retirement security system could grow worse over the next four years – much worse. That would be not just an ironic outcome of this election – it would be tragic.

(The opinions expressed here are those of the author, a columnist for Reuters)

“All told, the inequalities in our retirement security system could grow worse over the next four years – much worse. That would be not just an ironic outcome of this election – it would be tragic.”

Yes indeed, if Trump carries out the GOP agenda our retirement security system will shatter and the public will either blame Trump or the GOP. Preferably both, but that’s part of what’s going to be so fascinating to see now that the game of “blame for corporatist policy real-world consequences” hot-potato is in fully swing and the only groups playing are Donald ‘the outsider’ Trump and the rest of the GOP. If the Congress privatizes Social Security and Medicare as it appears they’re now going to do after Donald Trump campaign on not touches those programs, what are Trump and his GOP allies in Congress going to do to deflect the inevitable blame? Well, there is one option, and it looks like it’s going to be the option they’re probably going to try to do: Blame Obama. And if that sounds absurd, check out Paul Ryan’s latest reason for why we need to privatize Medicare:

Esquire

The Republican Healthcare Plan: Gut Medicare and Blame Obama

Ladies and gentlemen, introducing Paul Ryan.

By Charles P. Pierce
Nov 11, 2016

My Walk To Work, November 11, 2016: Part Two.

Every few days, when I walk to the BlogCave, I stop at a local McDonald’s for one of their Triglyceride Festival breakfasts. Every time I’ve done this, there has been a table full of elderly gents sitting at the same table by the side door. (Yeah, elderly. They’re older than me.) All of them wear baseball caps. One of them always wears a cap that marks him as a “Vietnam Veteran.” Sometime last summer, I noticed that a couple of them had taken to wearing those familiar red baseball caps that told the world that the elderly gents were ready to Make American Great Again. Presumably, most of these guys, if not all of them, benefit from Medicare.

Gentlemen? May I introduce you to Paul Ryan, the zombie-eyed granny starver from the state of Wisconsin? Jonathan Chait in New York would like to explain to you all how you are about to get bamboozled into a worse life than you have right now.

“Your solution has always been to put things together, including entitlement reform,” says Baier, using Republican code for privatizing Medicare. Ryan replies, “If you’re going to repeal and replace Obamacare, you have to address those issues as well. … Medicare has got some serious issues because of Obamacare. So those things are part of our plan to replace Obamacare.”

Yep. That’s what’s going to happen to your healthcare, gentlemen. And he’s going to blame the black guy for it, and my money’s all on you guys buying that wholesale. It is, of course, a blatant lie, because Paul Ryan is the…say it with us now…Biggest. Fake. Ever.

The Medicare trust fund has been extended 11 years as a result of the passage of Obamacare, whose cost reforms have helped bring health care inflation to historic lows. It is also untrue that repealing Obamacare requires changing traditional Medicare. But Ryan clearly believes he needs to make this claim in order to sell his plan, or probably even to convince fellow Republicans to support it.

One of the few positions on which the President-elect was marginally consistent during the campaign was that he would not touch entitlements. However, his economic plan was so stuffed with vague nonsense that I am fairly sure this is what’s going to happen: Ryan will come up with some bullshit “stimulus” program that is larded with tax-cuts and other goodies, and he will offer it to the White House in exchange for his life’s dream of shredding what’s left of the social safety net. He will put together a big pot of offal, slap a label reading “Medicare” on it, and then peddle it to the suckers.

The guys at McDonald’s will find themselves choosing between cat food and insulin and it will be Barack Obama’s fault. Lovely.

“Yep. That’s what’s going to happen to your healthcare, gentlemen. And he’s going to blame the black guy for it, and my money’s all on you guys buying that wholesale. It is, of course, a blatant lie, because Paul Ryan is the…say it with us now…Biggest. Fake. Ever.”

Yes, we need to privatize Medicare because of Obamacare. Sure, that’s not remotely true and Paul Ryan and all the other GOPers who will be repeating this lie know it. But they also know that Donald Trump was just elected president based on an entire platform of easily falsifiable lies, so why not tell the country that they have to privatize Medicare because of Obamacare? It’s hard to see what the GOP has to lose? So get ready for Obama and Obamacare to be blamed for pretty much everything the GOP is about to do because there’s no way Trump or the rest of the GOP wants the kind of blame it’s going to deserve.

It all raises another interesting question about the Trump/GOP Obamacare replacement schemes: Since the final scheme will almost certainly reduce the amount of actual heath care in the country, regardless of whether that’s due to people losing their insurance or people getting moved to cheap “catastrophic”-only insurance that doesn’t cover their needs, will Obamacare somehow be blamed for the inevitable death panels? Private insurers will presumably play a death panel role under Paul Ryan’s Medicare privatization plans, but with the block-granting of social safety net healthcare programs like Medicare also part of the Ryan-agenda, it seems like state governments are also going to be make a large number of death panel-ish decisions. Either way, it’s going to be important to keep in mind that one of the consequences of the GOP’s total control of the federal government and the realization of a GOP corporatist entitlement reform dream is that one of the absolutely critical goals of the Trump and administration and GOP is somehow convincing as many Americans as possible of the necessity of letting people die from a lack of being able to pay for things like medical care. Especially after Medicare gets privatized, since the whole point of privatizing Medicare is to move the responsibility of covering potentially expensive healthcare in old age from the government (society) onto the individual. It’s a reminder that Making America Great Again isn’t just going to be about Making America Hate Again. It’s also going to require Making Americans Not Care About Each Other Again, which is sort of like hating, but not exactly.

On the campaign trail, President-elect Donald Trump promised not to touch Medicare or Social Security, but Trump’s selection of Tom Leppert to lead the “landing team” at the Social Security Administration may suggest Trump’s administration could move in a different direction.

CNN flagged Monday that Leppert, a former Dallas mayor, has been on record supporting the privatization of Medicare and Social Security.

Leppert revealed his privatization plan in 2012 when he was running in the Republicans Senate primary in Texas, according to CNN. The plans, which were archived and first discovered by CNN, reveal Leppert was a major supporter of privatization.

“I will never shy away from any issue, even the so-called “third rail” of entitlement reform. Talk to any young person today, and they will tell you Social Security and Medicare won’t be there for their generation,” Leppert wrote. “To preserve these vital programs, we first and foremost must not change anything for those ages 55 and older. These folks rely on their benefits and we’ve made a promise to them. But for younger workers, we need to provide Medicare subsidies for the purchase of certified private plans, raise the retirement age, encourage greater retirement savings, and launch an initiative of Personal Retirement Accounts to allow every American, not just the wealthy, to save and invest toward their retirement.”

Leppert went on to explain in more detail that he supports now House Speaker Paul Ryan’s plan

“I believe we must move to a system like that provided to Members of Congress. This premium support model would give seniors greater choice and independence. They can choose the plan that is right for them, with subsidies provided by Medicare. This would be gradually phased-in over time and would not affect anyone currently over the age of 55,” the plan said. “For younger individuals, when they reach retirement, they will receive a subsidy from the federal government that will allow them to purchase certified coverage plans. Those with the lowest incomes would receive more funds from vouchers and would be eligible for additional Medicaid coverage.”

Leppert didn’t win the primary bid for the Senate in 2012. He has most recently served as the CEO of Kaplan, the education and test prep company. He endorsed Trump early in the primary.

“I will never shy away from any issue, even the so-called “third rail” of entitlement reform. Talk to any young person today, and they will tell you Social Security and Medicare won’t be there for their generation,” Leppert wrote. “To preserve these vital programs, we first and foremost must not change anything for those ages 55 and older. These folks rely on their benefits and we’ve made a promise to them. But for younger workers, we need to provide Medicare subsidies for the purchase of certified private plans, raise the retirement age, encourage greater retirement savings, and launch an initiative of Personal Retirement Accounts to allow every American, not just the wealthy, to save and invest toward their retirement.”

Well, if Donald Trump has any intention of sticking to his campaign pledges to not touch Medicare or Social Security, he sure has a strange way of signalling it. Perhaps this is some sort of bold Trumpian style of leadership to bring people together by choosing a team with views different from his own? Or, you know, maybe it’s a signal that President-elect Trump is a malicious liar who was always planning on gutting these programs? We’ll find out!

Interesting report here from Lauren Fox about a Q&A with Sen. Orrin Hatch about Medicare. Hatch makes pretty clear that he supports the Ryan Medicare Phaseout plan (phasing out Medicare and replacing it with private insurance and vouchers.) But he also makes clear that he’s reluctant to do it unless Democrats give Republicans cover. As we predicated, a lot of this will come down to whether Democrats give Republicans cover to phaseout Medicare on a notionally bipartisan basis. He also makes clear that he thinks some form of phaseout will be necessary to afford the rest of Trump’s agenda. Read.

“As we predicated, a lot of this will come down to whether Democrats give Republicans cover to phaseout Medicare on a notionally bipartisan basis. He also makes clear that he thinks some form of phaseout will be necessary to afford the rest of Trump’s agenda”

Sen. Orrin Hatch (R-UT) said that Republicans will need to make changes to Medicare and other entitlements in order to ensure Donald Trump’s administration is fiscally responsible.

In an interview with reporters Thursday, Hatch said that making changes to Medicare was essential.

“I think we’re going to have to do that. We’re going to have to make it better,” Hatch said. “So it will take care of people because the current system is not working.”

When asked if entitlement reforms were going to be necessary to accomplish the Trump agenda, Hatch said, “I think that is probably the understatement.”

Hatch, the chairman of the Senate Finance Committee, made his comments after House Budget Chairman Tom Price told reporters earlier Thursday that the new GOP Congress likely wouldn’t take up Medicare until the middle of 2017, in a second budget reconciliation as part of the 2018 budget process. Hatch was far more vague about timing he wanted to see on Medicare.

“I don’t think it’s a fast type of a thing, but I would like it to be,” Hatch said.

Hatch said he wanted to see a more bipartisan approach and he remained vague about what blueprints he’s seen that he’d want to execute.

“I’ve gone through a wide variety of things and there are some ideas that I think are very good,” he said.

…

“When asked if entitlement reforms were going to be necessary to accomplish the Trump agenda, Hatch said, “I think that is probably the understatement.””

So let’s summarize: President-elect Trump campaigned on not touching Social Security or Medicare but also campaigned on a budget-destroying massive tax cut for the wealthy. And now that he won, the GOP has the opportunity to privatize these same programs like its wanted to do for decades. Not only that, but the GOP basically has to privatize these programs, in particular Medicare which isn’t as self-funding as Social Security, if its going to make those massive tax cuts law and just obliterate the federal government’s spending power going forward. Plus, don’t forget that if the GOP kills Obamacare as Trump has pledged to do, that puts Medicare on shakier footing too since Obamacare was keeping down the growth in health care costs. And in order to make the entitlement cuts, along with all the other spending cuts, that are going to be required to finance Trump’s tax cuts, the GOP must have Democratic support. Support that the Democrats are extremely unlikely to want to provide (let’s hope)

It all raises a serious question that will probably be looming over Congress during the Trump years: So how exactly is the GOP planning on threatening or blackmailing the Democrats into giving them the cover they need to legislatively loot the country without incurring all the voter wrath? Because we’re talking about trillions of dollars in potential looting that’s going to be at the GOP’s legislative fingertips, but they need Democrats to sign on board in order to avoiding turning what could be a once in a lifetime orgy of looting into a Phyrric victory that destroys the party’s reputation. So how is the GOP planning on getting that bipartisan cover? What sort of horrible legislation is the GOP threatening if it doesn’t get that bipartisan support? Bringing back child labor? Pro-lead-poisoningpolicies? Ted Cruz of the Supreme Court?

Considering the standard GOP agenda typically double as threats against society and life on earth in general, it’s hard to say what exactly the GOP might threaten that’s so uniquely bad that it forces the Democrats into providing that much needed cover. But don’t forget that we’re talking about trillions of dollars for the GOP’s oligarch backers at stake over the next couple of years so you can bet the GOP is already brainstorming. It’s possible they’ll just go ahead with the gutting without Democratic support and just try to blame it all on Obama. We’ll see what they come up with.

Donald Trump’s senior adviser Kellyanne Conway said Tuesday night that the President-elect was “open to hearing” alternatives to the Medicare program, including one put forth by House Speaker Paul Ryan.

Conway was responding to a question from “PBS NewsHour” host Judy Woodruff, who asked about Trump’s view of Ryan’s proposal that Medicare be phased out in favor of a “premium support system”—his term for privatization.

“President-elect Trump has made very clear that he wants to make good on the promises that we as a nation have made to the seniors who rely upon Medicare, and certainly the lower income Americans who rely upon Medicaid and other entitlements like Social Security, frankly, for those who receive that,” Conway began.

Still, she said, Trump was open to hearing “different solutions and better ways of doing things.”

“He will, I’m sure, take a look at Speaker Ryan’s proposal and other proposals,” she continued. “In this case, he will go ahead and look at alternatives, Judy, as long as it does not interfere with what he has said, his commitment to keep the promises to those currently relying on them.”

During the campaign Trump had vowed that he was “not going to cut Medicare or Medicaid.” Now, his transition website states that he will “modernize” Medicare, “so that it will be ready for the challenges with the coming retirement of the Baby Boom generation – and beyond” and “[m]aximize flexibility for States [sic] in administering Medicaid.”

…

“He will, I’m sure, take a look at Speaker Ryan’s proposal and other proposals…In this case, he will go ahead and look at alternatives, Judy, as long as it does not interfere with what he has said, his commitment to keep the promises to those currently relying on them.”

The pledge by President-elect Donald Trump and congressional Republicans to “repeal and replace” the Affordable Care Act beginning early next year has dominated the national policy debate since Trump, and the GOP swept to victory in last week’s election.

With potentially 20 million or more Americans threatened with the disruption or loss of their Obamacare insurance coverage in the coming years, Trump and GOP leaders are coming under mounting pressure to explain precisely how they would replace Obamacare once they pass legislation early next year to dismantle key elements of the program.

However, practically overnight the Republicans have substantially raised the stakes in their drive to reform the government health care system and cut costs. House Budget Committee Chair Tom Price (R-GA) told reporters on Thursday that the House GOP will likely push next year for major changes and cuts in Medicare, the premier health care program for 57 million seniors that has been the bedrock of retirees’ health coverage since the mid-1960s.

Price, who reportedly is being considered by Trump to head the Department of Health and Human Services, said that Republicans would likely move “within the first six to eight months” of Trump’s administration to begin implementing their plan. Key elements include raising the age of eligibility from 65 to 67 and gradually privatizing the system with government-issued vouchers or “premium supports” to defray the cost of insurance policies purchased on the open market.

Trump repeatedly promised during the presidential campaign that he would not cut Social Security or Medicare to control government spending and address long-term deficit problems. “So, you’ve been paying into Social Security and Medicare…but we are not going to cut your Social Security, and we’re not cutting your Medicare,” Trump said at a rally in Iowa in December 2015.

However, privatization of Medicare has long been a central feature of House Speaker Paul Ryan’s highly controversial budget proposals that enjoyed substantial GOP support in the House but never made it past the Senate. Now Ryan and other Republican House leaders believe that the election results are a mandate to push a bold agenda including Medicare reform – much to the dismay of advocates of the program.

“This is one case where there just seems to be a gross contradiction between something that Trump clearly stated and what the congressional Republicans are now talking quite openly about doing next year,” said Paul N. Van de Water, a senior fellow at the liberal Center for Budget and Policy Priorities. “I didn’t follow Trump’s promises verbatim over the campaign, but everybody certainly seems to have picked up the notion that he promised not to cut Social Security and Medicare.”

“It’s hard to see how one could square that with either premium support for example or certainly raising the Medicare age,” he added in an interview Friday. “Both of those are either reducing benefits or requiring people to pay more for the same benefits, which is essentially the same thing.”

For years dating back to the administration of President George W. Bush, Republicans have been advancing proposals for replacing traditional Medicare with some private system, but those proposals have never gotten very far. The latest iteration of that plan – to preserve traditional Medicare for those currently in the system but to pressure younger Americans to gradually shift to a voucher plan – was included in a major health care policy paper Ryan released June 22 called “A Better Way– Our Vision for a Confident America.”

“Medicare . . . by many measures has served seniors successfully since the1960s by providing access to health care for millions and contributing to longer life expectancies,” Ryan wrote. “Despite these successes, the program faces notable challenges, including a complex financial structure and projected spending growth that make the program unsustainable for the long term.”

“If we act now, this can mean that traditional Medicare will continue for those currently on the program or near Medicare eligibility,” he added.

Ryan said last week that Medicare would be up for review in the new Congress, although he did not signal a precise timetable or how he hoped to orchestrate passage of legislation that is certain to be met with a firestorm of opposition from AARP and other seniors’ advocacy groups, veterans and liberal Democrats.

House and Senate GOP leaders intend to use an obscure budget parliamentary maneuver called reconciliation to push legislation through in January to repeal Obamacare by a simple majority, without having to muster a 60-vote supermajority to overcome a Democratic filibuster.

House GOP leaders will likely use reconciliation to push through a second budget resolution for fiscal 2018 that includes their Medicare reform package, according to Price. When asked by a reporter for the publication TPM about timing for changes to Medicare, Price replied yesterday: “I think that is probably in the second phase of reconciliation, which would have to be in the FY 18 budget resolution in the first six to eight months.”

Tampering with Medicare is politically risky at best. The federally funded health care program covers much of the cost of hospital care, physician visits and drugs for those 65 and older. Medicare benefit payments totaled $632 billion in 2015 and accounted for 15 percent of the federal budget. Medicare is funded primarily with general revenues (42 percent), payroll taxes (37 percent), and beneficiary premiums (13 percent).

Medicare spending growth has slowed in recent years, according to an analysis by the Kaiser Family Foundation. While costs are expected to continue to grow more slowly in the future compared to historical trends, “there are signs that spending growth could increase at a faster rate than in recent years,” in part because of rising prescription drug spending, growing enrollment in Medicare, and increases in provider payments.

However, Ryan and other deficit hawks have long argued that Medicare’s spending trajectory is not sustainable as the population ages and more and more baby boomers seek coverage. He cites a Congressional Budget Office estimate that the Part A Hospital Insurance trust fund will be insolvent in 2026, four years earlier than previously projected.

The Republicans’ solution, in part, is to raise the Medicare eligibility age beginning in 2020 and moving Medicare toward a “premium support” model. Instead of continuing with Medicare’s current guarantee of paying for a certain level of coverage – roughly 80 percent or more for a hospital stay—a premium support or “voucher” plan would provide seniors with a fixed sum to purchase health care coverage on the private insurance market, according to an analysis by the Center for Budget and Policy Priorities.

The size of the premium support would likely vary by region, to account for regional differences in health care costs, according to the analysis. Moreover, it would provide enough of a subsidy to purchase a modest insurance plan, at least in the beginning.

Seniors could choose from a menu of private health care plans offering a wide range of coverage, and the government would pay the Medicare premium supports directly to the plan to subsidize the cost. Seniors would have to pick up the rest of the cost.

…

Van de Water, who wrote the CBPP analysis, said Ryan’s latest proposal leaves many questions unanswered, including whether it would address mounting co-payments and other out-of-pocket costs, or whether the vouchers would be tied to inflation to keep up with rising health care costs.

“I don’t think we have any idea under the current plan how fast the vouchers grow,” he said.

That is an important question because it goes to the fears of many critics that the voucher plan would fall far short of what seniors would need to purchase adequate coverage, and that it would shift more and more health care costs away from the government and to a rapidly aging population.

What’s more, as the government makes it more expensive to remain in traditional Medicare, younger and healthier seniors would likely gravitate to cheaper, individual health care plans while older and sicker seniors would continue to cling to traditional Medicare. That would put more and more financial pressure on the government program, further undermining its financial stability.

“That’s the general consensus on this,” Van de Water said. “Premium support would be a threat to traditional Medicare.”

“For years dating back to the administration of President George W. Bush, Republicans have been advancing proposals for replacing traditional Medicare with some private system, but those proposals have never gotten very far. The latest iteration of that plan – to preserve traditional Medicare for those currently in the system but to pressure younger Americans to gradually shift to a voucher plan – was included in a major health care policy paper Ryan released June 22 called “A Better Way– Our Vision for a Confident America.””

Ooo…vouchers! What a nice replacement. So instead of Medicare covering 80 percent of your healthcare costs, you’ll get a fun fun fixed-value subsidy and be liable for everything beyond that:

…

The Republicans’ solution, in part, is to raise the Medicare eligibility age beginning in 2020 and moving Medicare toward a “premium support” model. Instead of continuing with Medicare’s current guarantee of paying for a certain level of coverage – roughly 80 percent or more for a hospital stay—a premium support or “voucher” plan would provide seniors with a fixed sum to purchase health care coverage on the private insurance market, according to an analysis by the Center for Budget and Policy Priorities.

The size of the premium support would likely vary by region, to account for regional differences in health care costs, according to the analysis. Moreover, it would provide enough of a subsidy to purchase a modest insurance plan, at least in the beginning.

Seniors could choose from a menu of private health care plans offering a wide range of coverage, and the government would pay the Medicare premium supports directly to the plan to subsidize the cost. Seniors would have to pick up the rest of the cost.

…

Van de Water, who wrote the CBPP analysis, said Ryan’s latest proposal leaves many questions unanswered, including whether it would address mounting co-payments and other out-of-pocket costs, or whether the vouchers would be tied to inflation to keep up with rising health care costs.

“I don’t think we have any idea under the current plan how fast the vouchers grow,” he said.

That is an important question because it goes to the fears of many critics that the voucher plan would fall far short of what seniors would need to purchase adequate coverage, and that it would shift more and more health care costs away from the government and to a rapidly aging population.
…

“That is an important question because it goes to the fears of many critics that the voucher plan would fall far short of what seniors would need to purchase adequate coverage, and that it would shift more and more health care costs away from the government and to a rapidly aging population.”

That’s what’s in store for the next generation during their twilight years: government vouchers that will help cushion the financial blow a tiny bit as you’re forced to liquidate your savings and assets to stay alive. Thanks President-elect Trump!
So while those currently on or near Medicare eligibility age should no doubt be giving thanks for Medicare this Thanksgiving, that doesn’t mean younger generations don’t also have Medicare-care-related thanks to give. Because selling off all your personal assets and effectively bankrupting yourself so you can qualify for Medicaid is going to be the only way to cover an expensive medical conditions after the GOP gets done gutting Medicare and phasing in “premium support” vouchers. At least that’s how it’s going to be for younger Americans. So if you’re a younger American, give thanks for what you have. Because you aren’t going to be able to keep it. Everything you have is going to have to go. Or you go. So be thankful for what you have while you still have it!

Well, it’s getting about as official as it can get without being formally official: Donald Trump and the GOP are planning on repealing Obamacare without any meaningful replacement. And what makes this eventuality unofficially official? Rep. Tom Price, one of the biggest backers for privatizing Medicare and repealing Obamacare completely, just got nominated to be the new secretary of Health and Human Services. Sorry Grandma!

And within two minutes of Trump’s transition team announcing that Price would be his nominee, Trump just happened to declare that burning the US flag should be punished with a loss of citizenship. Yes, almost immediately after Trump’s team announced a truly terrifying pick for HHS, Trump decides to terrify the nation with a completely different leadership horror show.

So the president-elect either just employed some sort of cowardly Machiavellian public relations scheme to distract the public from the fact that Trump just strongly signaled that Obamacare is going to be replaced with a joke and Medicare privatization is on the agenda, or the president-elect is just an unhinged demagogue with a Twitter account and lucky timing who has no idea what he’s supposed to be doing as president and is just going to let the rest of the GOP run his administration. Either way, with Price as the head of HHS it’s now unofficially official that Obamacare isn’t going to be healed. It’s going to be killed…now look at this shiny object!:

Atlanta Journal Constitution

A first move to dump Obamacare? Let’s talk about flag-burning

Greg Bluestein
Jim Galloway

November 29, 2016

At 6:53 a.m. today, the transition machine of Donald Trump announced that U.S. Rep. Tom Price of Roswell would be the president-elect’s choice for secretary of the U.S. Department of Health and Human Services.

This is the Trump administration’s first concrete move to fulfill the candidate’s promise of dumping the Affordable Care Act, perhaps the most volatile domestic aspect of the New York businessman’s victory. For it could deprive millions of a benefit, i.e. health care insurance, that is now in hand.

Within two minutes of his announcement, at 6:55 a.m., the president-elect decided we really ought to be talking about something else:

Nobody should be allowed to burn the American flag – if they do, there must be consequences – perhaps loss of citizenship or year in jail!— Donald J. Trump (@realDonaldTrump) November 29, 2016

Never mind that flag-burning isn’t much of an issue, and has been litigated before the U.S. Supreme Court, which decided it was protected by the First Amendment.

A shift away from the explosive could also be seen in Price’s formal response to the new job offer:

“There is much work to be done to ensure we have a health care system that works for patients, families, and doctors; that leads the world in the cure and prevention of illness; and that is based on sensible rules to protect the well-being of the country while embracing its innovative spirit.”

Nowhere in Price’s statement do the words “Obamacare” or “repeal” or “replace” appear.

The question right now isn’t whether Republicans have plans to repeal Obamacare. It’s which parts of which plans they’ll pick — and how quickly they’ll coalesce around one option.

But in choosing Price, Trump is signaling that he is serious about dismantling Obamacare. He has found one of the law’s most ardent, knowledgeable, and prepared opponents, and put him in charge of the effort.

…

“But in choosing Price, Trump is signaling that he is serious about dismantling Obamacare. He has found one of the law’s most ardent, knowledgeable, and prepared opponents, and put him in charge of the effort.”

So long Obamacare! We hardly knew thee…thanks in large part to the endless right-wing successes at undercuttingprovisions that would allow it to function. And now we’ll get to see what magical plan the GOP has to replace it. Hmmm…might it involve a lot of hand waving and references to “the market” and assurances that “the market” will take care of everything if only we give it a chance? Yes, it might involve that.

The Republican surgeon from Georgia, tapped to head the Department of Health and Human Services, espouses a more privatized approach to healthcare.

By Francine Kiefer, Staff writer
November 29, 2016

Washington — Donald Trump is indeed serious about repealing and replacing the Affordable Care Act. And to show just how serious he is, on Tuesday he chose conservative Rep. Tom Price to lead the Department of Health and Human Services.

Representative Price, a Republican doctor from Georgia, not only stridently opposes Obamacare. He has also put forward legislation to replace it in every Congress since the bill was passed in 2010.

If putting Price in charge of HHS is like “asking the fox to guard the hen house,” as Sen. Chuck Schumer (D) of New York puts it, that’s fine with Republicans.

At last, under unified GOP control in Washington, Republicans have an opportunity to act on their vision of healthcare for America – a vision that greatly reduces the role of the federal government in health decisions.

“The Republican approach is designed to focus on the individual, the patient – not on a government program,” says G. William Hoagland, senior vice president of the Bipartisan Policy Center. “It’s a very private-sector oriented approach to healthcare.”

If the Senate confirms Price as secretary of HHS, he will oversee a $1 trillion budget, about 80,000 employees, and nearly a dozen divisions – from Medicare and Medicaid to the Food and Drug Administration.

“This is the absolute perfect choice,” said Speaker Ryan in a statement.

Key changes

Republicans are expected to attempt to repeal the ACA early next year, through a budgetary process that requires only a majority vote in both houses for approval. They used the same process in 2015, gutting much of the law. President Obama vetoed it.

But the bigger challenge has always been to agree on a replacement. Republicans have circulated various proposals for replacing the ACA over the years, but they have not come to a consensus.

In the House, at least, they now seem to have generally settled on a series of points outlined in a document called “A Better Way,” which Price supports.

In the document, Republicans would keep popular provisions of the ACA, such as having pre-existing conditions covered and allowing young people to stay on their parents’ insurance.

But they would drop the federal and state “marketplace exchanges” set up under the ACA. As individuals and families begin 2018 enrollment in the exchanges, many of them are facing skyrocketing premiums and far less choice among plans – though they do get federal subsidies to help bear the cost increases.

The Better Way outline would instead help people purchase insurance on the open market with the help of refundable tax credits. Price, Ryan, and President-elect Trump also all favor health insurance that is available across state lines. And they would provide greater incentives for people to put away pre-tax dollars in health savings accounts.

For those who are priced out of these policies, the House Republican plan calls for federally subsidized “high-risk pools” and for Medicaid (healthcare for the poor) to be devolved to the states in the form of bloc grants or based on a state’s population.

…

Repeal first, then find a replacement

Critics – and not just Democrats – point to weaknesses in the Better Way plan. Medicaid grants to the states run the risk of failing as a safety net during times of recession, for instance. States are required to balance their budgets, yet the number of poor people who would need Medicaid increases during hard times.

Also, high-risk pools were tried before the ACA fully took effect, and didn’t work particularly well, says Derksen, who is a Republican. “It’s hard to make insurance work when you’re only covering sick people,” he says.

He also worries about insurers and Big Pharma having too much sway if the marketplace exchanges are eliminated. He prefers to see the exchanges modeled along the lines of Tricare, the military plan that goes out to bid among insurers.

Then there’s the question of whether the GOP promise to retain the popular aspects of the ACA is doable without the various mandates to purchase or offer insurance, a point that Senator Schumer raises.

Such criticisms will make it far more difficult to replace the ACA than to repeal it.

That’s why House Republican majority leader Kevin McCarthy of California told reporters on Tuesday that the plan is to repeal first, then set a transition period in which the law would still be in effect while lawmakers would hash out a replacement.

The replacement would have to be bipartisan if it is to get past the 60-vote threshold in the Senate that’s now required for most legislation, Rep. McCarthy said. A slew of Democratic senators from red states who face reelection in 2018 may well feel pressure to compromise with the GOP on a replacement.

At the same time, not all Republicans in the Senate may agree with their House colleagues.

Bigger fight: Medicare

Based on Democrat reactions on Tuesday, the bigger fight is likely to be over changes to Medicare – which Price sees as a cost-cutting priority for the next Congress. He and Ryan want to raise the eligibility age to 67 and transition it to a “premium support” program where seniors are provided vouchers to help them buy health insurance.

On the campaign trail, Donald Trump promised not to touch Medicare. Now his transition website says it will “modernize Medicare” to preserve it for future generations.

“We are going to fight tooth and nail any attempt to privatize, voucherize, or any other ‘ize’ you can think of when it comes to Medicare,” said Senator Schumer, in remarks to reporters on Tuesday.

In 2012, when Ryan was Mitt Romney’s vice presidential running mate, Democrats ran a memorable ad based on Ryan’s plan to turn Medicare into a partial voucher system. The “granny” ad, which depicted a Ryan look-alike pushing an elderly woman in a wheelchair over a cliff, was politically devastating for Republicans.

“Voters are largely insured. So talking about the ACA is one thing. But messing with Medicare is another,” says Democratic pollster Celinda Lake in an email.

There is a reason Trump had to say otherwise on the campaign trail, says Ms. Lake. “Medicare’s favorability is 65-66 percent – significantly higher than most of the politicians who want to cut or do away with it.”

“On the campaign trail, Donald Trump promised not to touch Medicare. Now his transition website says it will “modernize Medicare” to preserve it for future generations.”

Oh my. Could it be that Donald Trump lied on the campaign trail about not touching Medicare? Imagine that. Well, enjoy your vouchers, everyone:

…
Based on Democrat reactions on Tuesday, the bigger fight is likely to be over changes to Medicare – which Price sees as a cost-cutting priority for the next Congress. He and Ryan want to raise the eligibility age to 67 and transition it to a “premium support” program where seniors are provided vouchers to help them buy health insurance.
…

Yes, let’s remove the government’s bargaining power that’s a critical aspect to Medicare’s cost savings, and instead just throw all seniors into the private marketplace. With a voucher. What could possibly go wrong?

But, hey, maybe it won’t be that bad. After all, as the above article suggested, any sort of Medicare overhaul is going to have to be a bipartisan affair to overcome the filibuster in the Senate:

…
The replacement would have to be bipartisan if it is to get past the 60-vote threshold in the Senate that’s now required for most legislation, Rep. McCarthy said. A slew of Democratic senators from red states who face reelection in 2018 may well feel pressure to compromise with the GOP on a replacement.
…

Maybe there’s going to be a slew of Democrats eager to join the GOP is passing what could be the most politically toxic act in a generation and gut Medicare. We’ll see!

Rep. Tom Price (R-GA), the chairman of the budget committee, told reporters on Thursday that Republicans are eyeing major changes to Medicare in 2017.

Price, who is being floated as a possible Health and Human Services Secretary in the next administration, said that he expects Republican in the House to move on Medicare reforms “six to eight months” into the Trump administration.

Privatization of Medicare has been a central feature of Speaker of the House Paul Ryan’s budget proposal for years, and the House GOP has voted in favor of it multiple times. Ryan himself said last week that Medicare would be on the table in the new Congress, signaling it could be taken up early in the new year. Price’s comments suggest privatization won’t be part of the first round of legislative initiatives rolled out by the Trump administration and GOP-controlled Congress.

Price also noted that Republicans are eyeing using a tactic known as budget reconciliation to make the change. That process allows Republicans to pass bills with a simple majority in the U.S. Senate.

When asked by TPM about timing for changes to Medicare, Price said “I think that is probably in the second phase of reconciliation, which would have to be in the FY 18 budget resolution in the first 6-8 months.”

Republicans plan to tackle the Affordable Care Act in the first budget reconciliation process, which could take place as early as January. Tackling Medicare reform and Obamacare repeal at the same time could prove too high a risk for Republicans who have yet to reveal a clear plan to replace Obamacare with.

…

“Price also noted that Republicans are eyeing using a tactic known as budget reconciliation to make the change. That process allows Republicans to pass bills with a simple majority in the U.S. Senate.”

As Price makes clear, the GOP is planning on killing Obamacare in the first half of 2017, and then killing Medicare in the second half. And no filibuster is going to be able to stop it. That was Tom Price’s message to the world at a time when he was openly being considered for Secretary of HHS.

It all raises a mountain of questions. Not so much questions about what the GOP is going to do. They’ve made that pretty clear even if the details need to be worked out.

No, the big question raised at this point is what exactly is the Trump administration planning on doing to keep the American public distracted from the fact that his administration is going to spend its first year flip-flopping on one of his key campaign pledges and instead killing one of the most beloved government programs in US history. He already suggested stripping flag burners of their citizenship and that was just a one day distraction from the announcement of Price as his HHS nominee! And when you considering that almost all of Trump’s bizarre, distracting tweets and antics seem to center around him behaving like an out of control wannabe dictator with a major personality disorder, it’s not like there isn’t a distraction-template at this point. So what sort of giant, endless “don’t look at the Medicare privatization” distraction does Trump and the GOP have in store for us? We’ll unfortunately find out! And we’ll learn a very unfortunate lesson in the process: As bad as the Trump administration seems, it’s actually much, much worse because all the bad stuff you’re seeing is just a distraction from even worse stuff. Sad!

Surprise! A key House GOPer, the chair of the House Ways and Means subcommittee on Social Security, Sam Johnson, is proposing major cuts to Social Security. Oh wait, that’s not a surprise at all. Although the fact that they’re openly coming out and calling for such cuts without more smoke and mirrors and hand waving is a little surprising. The “reforms” are also almost exclusively in the form of benefit cuts, with no additional revenues coming into the system. So that’s also a little surprising given the political toxicity of such a move. Couldn’t they tack on at least some sort of tiny increase in revenue? Nope, apparently.

A key House Republican on the issue of Social Security introduced a bill Thursday that would impose major cuts to the program. The bill, the Social Security Reform Act of 2016, was introduced by Rep. Sam Johnson (R-TX), the chair of the House Ways and Means subcommittee on Social Security.

It would, among other things, gradually raise the retirement age from 67 to 69 on Americans 49 or younger at the present. It would change the formula that determines the size of a retiree’s initial payments. And it would switch the program to a less generous formula for raising payments according to cost of living increases.

Big picture, the most concerning element for many experts is that its approach to make the program more solvent rest entirely on cuts, and does not raise revenues for the Social Security Trust Fund, as some bipartisan proposals have. Across the political spectrum, solutions for long term solvency range from cuts-only approaches like Johnson’s bill to plans that achieve 75-year solvency by raising the current income cap on social security taxes.

“Ultimately, we are going to need something that’s a little more balanced between benefits saving and revenue changes in order to get a proposal that could pass Congress and get approved by the president,” said Shai Akabas, director fiscal policy at the Bipartisan Policy Center.

The cuts in the bill lean more heavily on high income-earners, but most workers would see cuts — some of them drastic — if Johnson’s bill became law.

The initial cuts come in the form of the two-year retirement age increase, which according to Paul Van de Water, a senior fellow at the left-leaning Center on Budget and Policy Priorities, amounts to a seven percent cut each year.

The changes to the formula to determine the initial benefit — known as the Primary Insurance Amount (PIA) — are more complicated and involve multiple moving parts. In general though, they negatively impact higher earners the most.

“The change in the formula, it’s structured so that it produces the largest decreases on benefits for the people with the highest pre-retirement earnings,” Van de Water said.

Almost all beneficiaries, however, would see reductions as time went on when compared to current law, due to the legislation’s use of a less generous inflation metric.

“That’s another cut in benefits, and one that grows the longer the person is on the benefit rolls,” Van de Water said.

Some low wage earners — particularly those who have participated in the workforce the longest — are shielded from these cuts due to an increase minimum benefit the legislation includes that acts as a floor for those at the bottom of the scale.

A letter from the Social Security Administration’s Chief Actuary gives a more concrete picture of what the legislation would like if implemented. On the low end of the scale, for retirees who have been in the workforce the longest, a 65-year-old who made an average of $12,280 (according to an established formula called AIME) after being in the workforce for 30 years would see his benefits increase by 9 percent when he retired in 2030, as compared to the current law. A 65-year-old retiree at the earning level who was only in the workforce for 20 years would see 19 percent decrease, however, in 2030. That cut would be 32 percent, if the 65-year-old was retiring in 2050.

Up the earning scale, the reductions continue. A 65-year-old middle-income earner, someone who earned an average of $49,121 after 44 years in the workforce, would see a reduction in her benefits of 11 percent when she retired in 2030, compared to the current law. The amount of reduction would increase the longer she stayed on the rolls: when she was 75 years old, for instance, the reduction would be 14 percent compared to current law, and 16 percent when she was 85 years old.

And the cuts get more severe the later a middle-income earner is retiring. If a 65-year-old at that earning level retired in 2050, her benefits would be 17 percent less than current law. By the time that retiree was 75 years old, they would be 19 percent less, and when she was 85, 22 percent less.

A 65-year-old at the top of the scale, a $118,500 average earner, would see his benefits cut by 25 percent when he retired in 2030, compared to the current law, and that reduction would grow to 55 percent compared to current law by the time the retiree was 85 years old. Likewise, those cuts get larger the longer the law is in place. The 65 year-old at the top of scale who retires in 2050 will see a 43 percent cut in his benefits, compared to current law, that will grow to a 74 percent reduction by the time he is 85.

Additionally the Johnson’s bill makes some notable cuts to spousal benefits, while introducing some means-testing provisions.

The Republican proposal comes as GOP lawmakers are in the midst of figuring out a plan to implement an Obamacare repeal, which, according to health policy experts stands to kick millions of their insurance. Hints that Republicans may consider Medicare privatization were met with a swift rebuke by Democrats, who vowed to go to war over the program. Many pointed out that President-elect Donald Trump campaigned on protecting social safety net programs.

…

“Almost all beneficiaries, however, would see reductions as time went on when compared to current law, due to the legislation’s use of a less generous inflation metric.”

Yep, the longer you live, the bigger your cut given that one of the main cuts comes in the form of a less generous inflation metric. Also, the younger you are, the bigger your cut too. So if you’re planning on living a long life which, you know, costs money to do, you might not want to plan on retiring.

Keep in mind that it’s possible this is all some sort of bait and switch where the GOP is setting up a draconian plan that Donald Trump swoops in to blocks as part of some sort of elaborate GOP theatrics for the 2020 election – theatrics that rely on turning the GOP into a monster for Trump to slay in order to convince voters to vote for Trump and that monster in upcoming elections. Except that gutting Social Security has long been one of the party’s goals and this is a once-in-a-generation chance for the GOP to pass virtually all of its long-held Koch Brothers/Paul Ryan fascist agenda that they’re not going to casually pass up.

And don’t forget that if this comes to pass, it would happen under an administration and Congress that’s about to pass a massive tax cut for the super-rich. The fact that proposals like gutting social security are are happening side by side massive tax cuts for rich is, in itself, an indication of what kind of tactics the GOP is going to be relying on: the same tactic is always relies on…act like a bunch of fascists and hope the right-wing media environment can keep the rubes distracted and confused. It’s worked pretty well so far!

Could that same tactic work even when the GOP fully puts its agenda into practice and doesn’t have the Democrats to blame? We’ll see! If the GOP is operating on the assumption that the majority of voters are brain-dead buffoons, there’s no reason a GOP Dark Age isn’t what we should expect next, even in this day an age of complete GOP control. They’re not passing up this opportunity if that’s the conclusion they’ve come to and the fact that this Social Security “reform” plan is coming at the same time that the party is planning massive tax cuts for the rich is a pretty big indication that they really have come to the conclusion that they can basically do anything and largely get away with it. Anything. Like converting the Social Security Trust Fund into a tax cut for Trump’s billionaire buddies:

Talking Points Memo
Editor’s Blog

Going for the Big Enchilada

By Josh Marshall
Published December 9, 2016, 1:18 PM EDT

Republicans apparently aren’t going to be satisfied with phasing out Medicare. They’re going to try to pass huge cuts to Social Security this year too. Not Bush-style partial phaseout but just big, big cuts. And you’re out of luck even if you’re a current beneficiary.

More shortly.

We’ll have more on this shortly. But reviewing the summary of the GOP bill, keep the following in mind. If you’ve been working for any number of years, but especially if you’ve been working for two or three decades, you’ve been paying in not only money for current beneficiaries but additional money which was invested in US government bonds to make it possible for Social Security to pay benefits of Baby Boomers and Gen-Xers. The additional money was required since there will be more seniors relative to the working age population.

This plan appears to foresee the government never paying that back to Social Security. In other words, your payroll taxes have been socking away additional money to cover the growing senior population. But this bill says too bad. That money goes for high income tax cuts.

“This plan appears to foresee the government never paying that back to Social Security. In other words, your payroll taxes have been socking away additional money to cover the growing senior population. But this bill says too bad. That money goes for high income tax cuts.”

While the GOP’s plan for replacing Obamacare is still a mystery, it’s not entirely a mystery. This is a GOP plan, after all. And like all GOP plans, we know the only thing it’s going to accomplish is a furtherance of the far-right’s endless quest to create a joke society run by and for oligarchs. It’s just a question of how it goes about furthering that overarching goal.

The GOP’s ‘Universal Access’ Health Care Plan Leaves Much to the Imagination

By Rob Garver
December 16, 2016

Republicans on Capitol Hill, vowing to repeal the Affordable Care Act the moment the next Congress is gaveled in, are fighting back against grim warnings that doing so will mean millions of people will lose their health insurance policies. A senior House leadership aide, in a briefing with reporters Thursday, conceded that the Republican plan would likely result in fewer Americans having health coverage — but that will be because they choose not to purchase it.

One of the key underpinnings of the Obamacare and its most controversial element is the individual mandate that requires Americans to either carry health insurance or pay the penalty. (The law includes large subsidies for many low and moderate-income people in order to make health insurance affordable.) The point of the mandate is to come as close as possible to universal coverage — a world in which virtually everyone is insured.

While universal coverage has a very obvious warm-and-fuzzy appeal to those who believe that health care should be available to everyone who lives in the world’s wealthiest country, it also has a powerful underlying economic rationale based on the realities of the insurance market. By requiring everyone to buy into the health insurance market, the healthy, who on average consume less health care than the sick, effectively subsidize their coverage.

Many opponents of the ACA, particularly those with a libertarian bent, see this as an unacceptable coercive “taking” by the government, arguing that people should not be forced to purchase something they may not want. Supporters of the law have claimed that because of the unpredictability of illness and accident, nobody can truly opt out of the health insurance market and that the mandate is the best solution to the free-rider problem — uninsured people seeking emergency care that they often cannot pay for but that hospitals are obligated to provide.

While the details of what the Republicans intend to replace the ACA with remain sketchy, one of the goals expressed in Thursday’s briefing, as reported by The New York Times, will be to replace the principle of universal coverage with something quite different: universal access.

The idea is that having health insurance will not be a requirement, the unnamed aide said, but will be a viable option for anyone who wants it.

“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” the aide reportedly said.

The details remain to be worked out, and that will be no small task if indeed it is achievable at all.

The problem lies in the basic economics of the health insurance market. Without a mandate to purchase insurance, the people who see the least value in it — younger, healthier consumers — are likely to decline to buy it. The result is a pool of insured people who are older and sicker on average than the population as a whole.

That is a more expensive group of people to cover, and health insurers used to have two options for dealing with a pool of potential customers who were sicker than the population as a whole: raise prices or deny coverage to sick or high-risk patients.

However, the ACA removed that second option, requiring insurers selling policies through the health insurance exchanges to extend coverage to all applicants. (Indeed, the individual mandate was the trade-off that insurers accepted in exchange for dropping limitations on pre-existing conditions.) Repealing that part of the law would be wildly unpopular, and indeed President-elect Donald Trump has said that he does not support doing so.

This leaves price increases as insurers’ only option — short of leaving the exchanges completely — for dealing with a sicker population. Supporters of the ACA argue that this is just the first step in a vicious cycle. As costs go up, healthier people start to question whether the value they receive from their insurance policy is worth the cost and more of them will drop their policies, leading to further premium increases for those who remain, and so on and so on.

How Republicans plan to address this problem is unclear. Over the past few years, proposals for subsidized high-risk pools meant to take the sickest patients out of the general insurance pool have been floated, but whether they would be viable remains a question.

…

What isn’t immediately known is how the next Congress will handle the individual mandate. Leaving it in place during the transition period would be seen by many of the ACA’s most ardent opponents as a betrayal. But eliminating it could cause insurers operating in the health care exchanges to rush for the exits, creating a major coverage crisis for millions of Americans and resulting, at least in the near term, in the exact opposite of “universal access.”

“Republicans on Capitol Hill, vowing to repeal the Affordable Care Act the moment the next Congress is gaveled in, are fighting back against grim warnings that doing so will mean millions of people will lose their health insurance policies. A senior House leadership aide, in a briefing with reporters Thursday, conceded that the Republican plan would likely result in fewer Americans having health coverage — but that will be because they choose not to purchase it.”

Yes, at the same time the GOP is laughingly trying to dismiss fears that their Obamacare replacement is going to lead to a loss of healthcare coverage, we now have word coming from the House leadership that the new plan centers on repealing the goal of universal coverage and replacing it with a goal of universal access.

And yet there’s no clear GOP plan for doing this. Not just because the GOP hasn’t given any indication of how it plans on achieving this new universal coverage goal, but also because such a goal implies that the GOP will keep the popular provision of Obamacare prevents people from being denied coverage due to pre-existing conditions. And keeping such a provision while dropping the mandate that people get coverage sort of defies the economics of health care:

…

The idea is that having health insurance will not be a requirement, the unnamed aide said, but will be a viable option for anyone who wants it.

“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” the aide reportedly said.

The details remain to be worked out, and that will be no small task if indeed it is achievable at all.

The problem lies in the basic economics of the health insurance market. Without a mandate to purchase insurance, the people who see the least value in it — younger, healthier consumers — are likely to decline to buy it. The result is a pool of insured people who are older and sicker on average than the population as a whole.

That is a more expensive group of people to cover, and health insurers used to have two options for dealing with a pool of potential customers who were sicker than the population as a whole: raise prices or deny coverage to sick or high-risk patients.

However, the ACA removed that second option, requiring insurers selling policies through the health insurance exchanges to extend coverage to all applicants. (Indeed, the individual mandate was the trade-off that insurers accepted in exchange for dropping limitations on pre-existing conditions.) Repealing that part of the law would be wildly unpopular, and indeed President-elect Donald Trump has said that he does not support doing so.

This leaves price increases as insurers’ only option — short of leaving the exchanges completely — for dealing with a sicker population. Supporters of the ACA argue that this is just the first step in a vicious cycle. As costs go up, healthier people start to question whether the value they receive from their insurance policy is worth the cost and more of them will drop their policies, leading to further premium increases for those who remain, and so on and so on.

…

“This leaves price increases as insurers’ only option — short of leaving the exchanges completely — for dealing with a sicker population.”

Yep, that appears to be the GOP’s solution: keep Obamacare’s pre-existing condition mandate, drop the coverage mandate, and then…well, and then something else that will somehow prevent a premium price death-spiral. And there’s nothing that can realistically prevent that premium death-spiral that doesn’t somehow involve subsidizing insurers who are going to be forced to take on high-risk patients with pre-existing conditions. And as the article below notes, once Obamacare is repealed, the tax-increasing that are currently used to finance those insurer subsidies disappear too, which means if the GOP is going to avoid that premium price death-spiral it’s going to have to raise taxes. And that, of course, means there isn’t actually a GOP solution for avoiding a premium price death-spiral

Talking Points Memo
DC

Why The GOP’s Obamacare Repeal May Doom Their Replacement

By Tierney Sneed
Published December 15, 2016, 6:00 AM EST

The GOP’s most likely path for repealing Obamacare immediately eliminates hundreds of billions of dollars in tax revenue that would otherwise be available to fund their replacement plan.

The large tax cut, which would go disproportionately to high earners, will seriously handcuff lawmakers as they try to cobble together a replacement plan to cover the millions of Americans dependent on Obamacare for health insurance, health care policy experts say.

With Republican Party’s strict anti-tax orthodoxy, it is difficult to envision the new GOP-controlled Congress raising taxes down the road to fund their Obamacare replacement. So while the current plan of repeal and delay contemplates a future replacement plan, the lost tax revenues is perhaps the most telling sign that a viable replacement may be either impossible to achieve or a meager substitute.

So far, congressional leaders have signaled they’re eying a version of the 2015 bill that delayed some aspects of Obamacare repeal for two years, but dismantled its taxes right away.

Not only would that mean a major tax break for the high-earners, with cuts that are directed towards individuals making more than $200,000. It would also shut down right off the bat a potential revenue source for whatever alternative — if there ever is one — that GOP lawmakers settle on.

“If all the taxes in the ACA are repealed as part of a reconciliation bill, that could be hugely consequential,” said Larry Levitt, vice president at the Kaiser Family Foundation. “If you take all that revenue off the table, it means a replacement bill has to be very scaled back relative to the ACA or they have to find money from somewhere else to pay for it, both of which would involve difficult trade offs.”

The tax cuts for the high-earners come in the form of an additional Medicare tax on high-earners and a tax on net investment income, which would be repealed immediately, under the 2015 rubric. The legislation, which was passed via the procedural maneuver known as reconciliation, also repealed taxes on the health care industry. All told, $680 billion in tax revenue would be eliminated if GOP lawmakers pushed through the same bill they used a year ago, according to a Brookings report.

From a political sense, it’s easy to see why getting rid of the taxes is appealing to Republicans.

As a Ryan Ellis, former tax policy director for Grover Norquist’s Americans for Tax Reform, put it to Politico, the tax cuts are “the best part about repealing Obamacare.”

“Because on the health care side of it, you have this complicated ‘replace’ that you have to turn to after that, but on taxes, it’s all easy — it’s all dessert,” he said.

From a policy standpoint, it puts an additional hurdle in front of GOP lawmakers as they hammer out a replacement plan. Not only will they have to agree on what that plan should look like, but how to fund it.

“It’s so often the case with health care legislation that the disagreements come with how to pay for it, rather than what to spend the money on,” Levitt said.

It’s not like Republicans are typically comfortable with raising taxes, meaning they could land on a plan that would be paid for with cuts to other programs or that wouldn’t cost that that much in the first place.

“They are acknowledging by saying that, that they have no intention of replacing with something that will provide the equivalent coverage and affordability, because they won’t have the dollars to support it,” said John McDonough, a Harvard public health professor who wrote the 2011 book “Inside National Health Reform.”

“So what they’re looking at it will be a substantially degraded replacement plan in terms of the numbers of people who get coverage and the benefits for which they can get access to medical care,” he said.

Some of the replacement proposals that have been floated by Republicans include tax credits similar to the ACA’s subsidies that could cost billions. But funding the Affordable Care Act was no easy feat, and depended on a logic that those new taxes were justified for those who would be paying them.

“You’re expanding the market for health care, so some insurance companies and providers, like devicemakers, will make some money so it made some sense to tax them,” said Alice Rivlin, a former Clinton administration Office of Management and Budget who is now a fellow at the Brookings Institute.

…

“With Republican Party’s strict anti-tax orthodoxy, it is difficult to envision the new GOP-controlled Congress raising taxes down the road to fund their Obamacare replacement. So while the current plan of repeal and delay contemplates a future replacement plan, the lost tax revenues is perhaps the most telling sign that a viable replacement may be either impossible to achieve or a meager substitute.”

That’s right, the GOP’s most likely replacement for Obamacare is …*drum roll* …a tax cut for the rich!

Also keep in mind that increasing coverage so people get their health conditions addressed early on before they become far more severe and people end up in the emergency room at much higher expense is the only real way of lower long-term healthcare costs for individuals and society. Keeping people healthier is actually the path to lowering health care costs over the lifetime of an individual and society at large. Imagine that! At least it’s the only way to keep cost down that doesn’t abandon the notion that society shouldn’t abandon people in need of medical care. But it looks like the GOP is going to be pursuing the latter option.

Also keep in mind that, based on the vagueness of the “universal access” language the GOP is using, it’s possible that their plan for allowing people with pre-existing conditions to get access to insurance coverage is by forcing insurance at least some sort of plan to everyone, including plans that cover almost no conditions. Or any other conditions exacerbated by their pre-existing conditions Don’t forget that, before Obamacare, some people with expensive pre-existing conditions were not just forced to pay more for coverage but, in some instances, couldn’t find insurers that were willing to cover them at all. That being the case, the GOP could still sort of claim that their replacement actually does something to achieve “universal access” even if it simply mandates that everyone, regardless of their pre-existing conditions, gets offered some sort of plan by insurers, including a really crappy plan that covers almost nothing.

So while the GOP’s and Supreme Court’s act of ‘ripping off the Medicaid Bandaid’ three years ago by eliminating the Medicaid expansion mandate might have seemed like a disaster for the US’s health care system, get ready for the next phase in the GOP’s war on American healthcare: insurance policies that only cover an bandaid. With guaranteed access. At least that’s a possiblity we should watch out for. It hard to say what exactly the GOP’s plan is at this point. Except that a lot more people are going to lose their health care coverage. Even the GOP is admitting that at this point. Even as they deny it.

Oh, and we can also be sure that there’s going to be another tax cut for the rich. Of course.

In what may be an important shift, the overall impression that Republicans on the Hill are giving today is that they’re beginning to grapple at long last with some of the myriad political and policy downsides of Obamacare repeal. It’s still early, and we need more evidence of a real shift before we draw any firm conclusions. But this reporting from Lauren Fox suggests that one of the immediate consequences of growing GOP wariness may be a push from some members to ensure that some sort of replacement plan is passed at the same time as repeal.

Those who know the ins and outs of health care policy will quickly tell you that the replacement plan is the hard part and that it can’t be devised, debated, or passed quickly. We have seven years of no GOP replacement plans as Exhibit A for why it’s so hard. So if you’re a GOP member of Congress now saying you want to see a replacement plan along with a repeal plan, then you’re essentially saying, intentionally or not, that you want to push off repeal for a while.

Steven Dennis at Bloomberg reports this very telling exchange with an unnamed GOP senator:

A Republican senator on condition of anonymity said the details of the repeal bill remain very uncertain. Originally, Republicans were planning to simply bring back the bill they put on Obama’s desk last year for his veto.

But that bill was written knowing it wouldn’t become law, and now some Republicans want to make tweaks to soften the blow of repeal.

“Even people who voted for this before are, ‘Wait a minute, wait a minute, we knew that wasn’t going to happen,’” said the senator. “There were no consequences.” He said there’s a growing sense among some of his colleagues that they need to have a replacement for Obamacare ready soon “because we’re going to own this.”

The key element here is time. Coming up with a replacement takes time. Pushing off repeal for long risks not having the political juice down the road to take it up again, or having to do so on less favorable terms. Doing health care policy right isn’t a matter of good political messaging and well-applied bandaids to obscure what you’re really doing. It’s slow-going, and Republicans have boxed themselves in with promises of immediate repeal. Some of them seem to be figuring that out.

…

“”Even people who voted for this before are, ‘Wait a minute, wait a minute, we knew that wasn’t going to happen,’” said the senator. “There were no consequences.” He said there’s a growing sense among some of his colleagues that they need to have a replacement for Obamacare ready soon “because we’re going to own this.””

Uh oh. The Republicans are beginning to realize that their campaign pledge to ‘repeal and replace Omabacare’ was in reality a campaign pledge to break US healthcare for the foreseeable future. And maybe they’ll have to “own” it.

So what’s the GOP going to do given that the GOP is ideologically committed to rejecting any possible Obamacare replacement that might actually work? Will we see a surprise immediate replacement plan that at least avoids the scenario of leaving Obamacare in place for years with no planned alternative? It’s hard to see how that happens with the complete lack of any viable replacement models thus far and the time it takes to come up with a new one.

But there is another option, and it sounds like the option Donald Trump is already getting behind: the GOP can go ahead with the ‘repeal and replace (years from now)’ plan now, cross their fingers and hope it doesn’t turn out to be a total disaster, and it if does end up a disaster try to ensure the public blames the Democrats:

President-elect Donald Trump told Republicans in a series of tweets Wednesday morning to “be careful!” and make sure that Democrats take ownership of any failures of the Affordable Care Act, as the GOP takes its first steps towards repealing the healthcare law.

“Republicans must be careful in that the Dems own the failed ObamaCare disaster,” Trump tweeted, apparently warning Republicans to avoid acting in undue haste that might lead to poor optics. “Dems are to blame for the mess. It will fall of its own weight – be careful!”

Republicans must be careful in that the Dems own the failed ObamaCare disaster, with its poor coverage and massive premium increases……— Donald J. Trump (@realDonaldTrump) January 4, 2017

like the 116% hike in Arizona. Also, deductibles are so high that it is practically useless. Don't let the Schumer clowns out of this web…— Donald J. Trump (@realDonaldTrump) January 4, 2017

massive increases of ObamaCare will take place this year and Dems are to blame for the mess. It will fall of its own weight – be careful!— Donald J. Trump (@realDonaldTrump) January 4, 2017

House Republicans on Tuesday introduced and approved new chamber rules that included a special glide path for their efforts to dismantle Obamacare. Senate Budget Committee Chairman Mike Enzi (R-WY) also introduced a budget resolution to kick-start the budget reconciliation process Republican lawmakers will likely use to scrap major parts of the bill and avoid a Democratic filibuster.

…

““Republicans must be careful in that the Dems own the failed ObamaCare disaster,” Trump tweeted, apparently warning Republicans to avoid acting in undue haste that might lead to poor optics. “Dems are to blame for the mess. It will fall of its own weight – be careful!””

Yep, if the GOP repeals Obamacare but doesn’t actually have a replacement, and this market uncertainty leads to all sorts of problems like insurers dropping out of the market or rising premiums, that’s all the Democrats’ fault. And Trump actually feels the need to publicly instruct the GOP about this tactic going forward. As if the rest of the GOP needed to be reminded of this. And, of course, he decides to send the GOP this sage advice via Twitter, so we can all see his tips on how to improve the GOP’s optics in their plans to sabotage the country (he seems to enjoy the public tweets promoting better GOP corruption optics of late).

Over the next few weeks, Republicans will probably vote to repeal Obamacare. Though Republicans and vice president-elect Mike Pence are huddling to come up with replacement plans, the general framework of action over the immediate term seems clear. Republicans will likely delay its phase-out so as to not immediately cancel millions of plans and “create a transition and bridge so that no one is left out in the cold,”as per Speaker Ryan. Barring defections, Democrats have little power to stop them.

There’s one big problem with this approach, however. While the “repeal and delay” tactic seems like a way to keep people from becoming suddenly uninsured or having to make inconvenient changes—or to keep kicking the can down the road—in reality the mere announcement of a legally-binding repeal or pledge to end government support for federally-backed markets could cause severe disruptions in how those markets operate. And those disruptions could mean turmoil for millions of people.

The secondary currency of any insurance market is risk—or the amount plans can be expected to pay in claims for each beneficiary. Originally, insurers hedged against risk by finding healthy patients and charging sicker patients more or denying them coverage altogether. Obamacare effectively eliminated many of those hedges by creating qualifying health plans, by removing lifetime spending caps, and by prohibiting companies from refusing to insure based on pre-existing conditions bans. In order to make the health plans work work and entice health insurance companies to participate in the health insurance exchanges, Obamacare mandates healthier people to join and offset sicker people’s costs, and also uses federal money to offsetting risky bets in several different ways. Those shopping for plans on the exchanges are often inherently risky bets, and only federal funding and the promise of more such funding in the future keeps insurers insuring them.

Even in 2016 before Donald Trump’s presidency became viable and the threat of an Obamacare repeal became real, the exchanges had grown increasingly unstable and brittle. The administration had difficulty in attracting younger, healthier people to sign up, so enrollees were sicker and riskier than expected. Although stakeholders expected risk to be high as the country adjusted to a brand-new healthcare paradigm and the individual mandate pushed stragglers into exchanges, Congress later authorized lower payments than expected to offset that risk. The highly-publicized premium increases of exchange plans and the withdrawal of major insurers like Aetna were signs of this inherent instability. Although they are certainly fixable problems, fixing them requires money, which requires action by Congress.

Though some of this instability can be attributed to hype from insurers seeking to maximize government subsidies and payments to offset risk, several firms do run in the red now with the expectation that they’ll be in good position to make money when the market settles down.

What’s the incentive for them to continue to insure people if they believe the market will no longer exist—or if they believe that the tax credits in a Republican replacement plan are less than what they receive now? Insurance plans have to decide by May of 2017 if they’ll participate in the exchanges, and it might not be a surprise to see insurers with smaller enrollee bases or higher losses bow out. Also, those plans that do stay can pass on the costs of increased uncertainty in the markets in the form of increased premiums, which would cost the federal government and enrollees even more money.

At MarketWatch, former health-insurance executive J.B. Silvers explains how this might all work in practice:

Some in Congress seem to think that passing the “repeal” part immediately but delaying its implementation for two or three years will somehow leave everything as it is now. But this naive notion misses the fact that the riskiness of the Obamacare individual insurance exchange markets will have been ramped up to such a level that continuing makes no sense.

Even if a company reaches break-even in the “delay” years, it will lose when the repeal is effective. If the premium subsidies now available to lower-income enrollees go away immediately and the mandate to sign up for an insurance plan disappears, then the number of people purchasing individual policies on the exchanges will drop like a rock. In fact, it is clear that even debating this scenario is likely to be self-fulfilling, since insurers must decide on their participation for 2018 by the late spring of 2017. Look for many to leave then.

A plan to repeal and delay would also likely have some effects on the individual mandate to purchase insurance. If that plan immediately eliminates the mandate, the final lever to maintain the health of exchange risk pools evaporates, and there will be much less impetus for healthier, younger people to participate in them. Even if the plan phases the mandate out over time, news of a repeal might be easily misconstrued as eliminating the mandate, which could still spur millions of healthy people to leave the exchanges and penalize them at tax time next year for doing so. At the same time, even the rumor of a repeal can send millions of sicker people into the exchanges to receive some kind of vital services before the well runs dry, which are bound by law to cover them. In fact, this may already have happened. As long as an indefinite purgatory between repeal and replacement exists, adverse selection will be impossible to fix, as would be the “death spiral.”

The worst-case scenario would be the large-scale withdrawal of insurers from markets and the inversion of risk pyramids, with sicker and sicker patients seeking coverage while they can. Without available insurers or a public option, people without employer coverage or who make too much to qualify for Medicaid might just not have any insurance to buy. If Congress and state governments don’t actively enforce “rate review” and medical-loss ratio rules that give states oversight over large premium increases and mandate that insurance plans spend a certain percentage of premiums on healthcare, insurers could enter markets that don’t have plans and raise premiums for vulnerable people who need insurance most. Alternatively, short-term insurers—which already profit on the mandate despite providing barebones services that don’t qualify as full plans—could continue to fill in the gaps.

Millions of people in the exchanges may have to change insurance or enter the ranks of the uninsured. And though the delay may not immediately affect people with employer coverage or public coverage, downstream challenges for insurers in exchanges could affect the products they offer for those markets. None of this would be good politically for Republicans, who already have to contend with a voter base that actually kind of likes having insurance. Compare that scenario to the political damage that Democrats suffered in the 2016 elections over much less dire and far-reaching problems. Republicans could pin these woes on Obamacare itself, but then their inability to fix those woes despite campaigning on promises to do just that could come back to haunt them.

…

“Millions of people in the exchanges may have to change insurance or enter the ranks of the uninsured. And though the delay may not immediately affect people with employer coverage or public coverage, downstream challenges for insurers in exchanges could affect the products they offer for those markets. None of this would be good politically for Republicans, who already have to contend with a voter base that actually kind of likes having insurance. Compare that scenario to the political damage that Democrats suffered in the 2016 elections over much less dire and far-reaching problems. Republicans could pin these woes on Obamacare itself, but then their inability to fix those woes despite campaigning on promises to do just that could come back to haunt them.”

Yep, all the uncertainty (i.e. additional risk) that the GOP’s ‘repeal and replace (at some undetermined point in some undetermined form)’ scheme introduces into the insurance marketplace might not only lead to rising premiums, fewer options, and dropped coverage in Obamacare. That chaos could start bleeding into the rest of the insurance markets. All that blame that Trump warned the GOP to make the Democrats “own” could be a lot more blame than the GOP is currently expecting. And probably a lot more blame than Trump is expecting too since he doesn’t appear to actually know anything meaningful about health care or policy in general.

And that all points to a rather fascinating political dynamic that we could see emerge: The GOP knows it’s about to create a bad situation that’s set to get worse and it knows it might get the blame but also might be able to transfer that blame onto the Democrats if it’s gets the optics right. And that means the GOP knows it’s going to have to dedicate a good deal of its political messaging on creating the kinds of memes that will cause the public to blame Obama and the Democrats when things predictably go awry. And that means we just might see a situation where the GOP repeals Obamacare soon and then spends the next four years campaigning against Obamacare like they’ve done for the last seven years. Sure, that would seem really odd given the situation, but it’s an odd situation. But if the GOP does pursue that course of action (or, rather, course of inaction), the situation gets weirder and more perilous for the GOP. Why? Because the GOP is going to have a big incentive to keep talking about how things were getting worse with Obamacare before Trump and the GOP took over…without reminding the public of all the ways the GOP worked to ensure things would get worse for Obamacare

…Even in 2016 before Donald Trump’s presidency became viable and the threat of an Obamacare repeal became real, the exchanges had grown increasingly unstable and brittle. The administration had difficulty in attracting younger, healthier people to sign up, so enrollees were sicker and riskier than expected. Although stakeholders expected risk to be high as the country adjusted to a brand-new healthcare paradigm and the individual mandate pushed stragglers into exchanges, Congress later authorized lower payments than expected to offset that risk. The highly-publicized premium increases of exchange plans and the withdrawal of major insurers like Aetna were signs of this inherent instability. Although they are certainly fixable problems, fixing them requires money, which requires action by Congress.

…

“Although stakeholders expected risk to be high as the country adjusted to a brand-new healthcare paradigm and the individual mandate pushed stragglers into exchanges, Congress later authorized lower payments than expected to offset that risk. The highly-publicized premium increases of exchange plans and the withdrawal of major insurers like Aetna were signs of this inherent instability.”

Yep, those rising premiums that the GOP loved to complain about were due, in large part, to the fact that Congress killed the subsidies designed to avoid large hikes in premiums. But, of course, it wasn’t “Congress” that did do that. It was the GOP. And while Senator Marco Rubio was fond of taking sole credit during his presidential run for the loss of the subsidies that made be premium hikes a certainty, it was actually a GOP group effort that ensured those premium hikes:

“I’m the only one running for president that’s ever scored a victory against Obamacare. And I didn’t do it with a lot of fanfare, I just did it.… Last year, these companies lost money and they came to the government and said, where’s the bailout money you promised us in the law? It would’ve been about two and half billion dollars. And the government said, ‘We don’t have that money because Marco Rubio inserted, in the end-of-the-year budget, a provision. He was able to work to ensure this provision got in, that took away the bailout money.’”

— Rubio, speech in Muscatine, Iowa, Dec. 17, 2015

This is a story about a media narrative, abetted by a presidential campaign, that has unfairly misdirected the credit for one of the most important blows against the Affordable Care Act.

Indeed, the second part of the voiceover in the Super PAC ad comes directly from a New York Times article that, in its first sentence, said that Rubio had “slipped into a giant spending bill” in 2014 a “little-noticed health care provision” that had undermined confidence in Obamacare. The ad quotes other news reports as well.

Meanwhile, Rubio also has claimed that he inserted key language in the budget bill.

In reality, in the sausage making of the law, Rubio didn’t make the sausage that has wounded the law. He had wanted to make a different sausage. But through deft marketing, he managed to slap his name on this one.

So far, with the exception of a careful report in the Associated Press, much of the media have gotten this story wrong.

The Facts

At issue is something called “risk corridors” — a provision of the massive law that was intended to protect insurance companies from losses if they did not properly estimate premiums in the initial three years of the law. Companies that estimated correctly — and had what were deemed as excess profits — would pay fees to help underwrite at least some of the cost of helping the insurance companies that had stumbled.

While some health-care experts say risk corridors are an important feature to smooth out the transition to the new law, Republicans opposed such payments as a bailout for poorly run insurance companies — or ones that deliberately underpriced their products, knowing they would get government funds. Rubio in 2013 introduced a bill to eliminate the provision, but like other Obamacare repeal efforts, his proposal went nowhere.

It’s worth noting that Rubio does not sit on any committees involved with health-care policy. And it is in the committees that the real business of legislation often is done.

On Feb. 5, 2014, the House Committee on Oversight and Government Reform held a hearing on the “insurance company bailout.” Rubio testified on behalf of the bill he had filed. In a blow to GOP efforts, the Congressional Budget Office released an estimate the day before the hearing that the risk corridor provision would earn $8 billion for the U.S. government.

But a House probe that year actually suggested claims would exceed payments. Meanwhile, Sen. Jeff Sessions (R-Ala.), then ranking member of the Budget Committee, and Rep. Fred Upton (R-Mich.), chairman of the Energy and Commerce Committee, came up with a new strategy of attacking the legality of the payments. They also enlisted the help of then-Rep. Jack Kingston (R-Ga.), who chaired the appropriations panel that funds the Department of Health and Human Services and the Labor Department.

The lawmakers questioned whether the payments were actually appropriated correctly — forcing the administration to make changes that ultimately allowed the lawmakers to checkmate the administration. In effect, the Centers for Medicare and Medicaid Services (CMS) was forced to admit that the ACA did not automatically appropriate the funds, but it was subject to discretion of Congress. (A Government Accountability Office opinion requested by Sessions and Upton backed up much of the GOP contention.)

So the administration, which had asserted that the risk-corridor funds came from mandatory spending, designated the money as discretionary. Officials made a number of other changes, such as classifying the payments as “user fees,” in an effort retain the authority to spend the money. But if collections fell short, as Republicans expected, then the administration would need approval for the money from Congress.

“Successfully arguing that the ACA did not appropriate money for the risk-corridor program is what ultimately restricted payments to insurers,” said Paul Winfree, at the time a Sessions staff aide.

The stage was set for Kingston to slip in a sentence — Section 227 — in massive spending bill that said that no funds in the spending bill could be used for risk-corridor payments. This blocked the administration from obtaining the necessary funds from other programs.

Kingston says the conference negotiation consisted of basically him and his Senate counterpart, then-Sen. Tom Harkin (D-Iowa). “I think it was not seen as a big issue,” Kingston said. “He had won on so many things,” particularly on labor issues. So Kingston offered up a health-care request. “Part of these negotiations is you don’t get everything you wanted.”

Indeed, lawmakers and staff members say, stealth was essential for success, which is why they kept quiet about their achievement. Sessions, Upton and Kingston did not issue news releases — but Rubio did, saying the provision was “a step in the right direction.”

Kingston’s maneuver ultimately left a $2.5 billion shortfall in the risk-corridor program in 2015, as the administration only collected $362 million in user fees — and insurers who misjudged the market sought nearly $2.9 billion in payments. Nearly a dozen nonprofit insurance cooperatives have failed as a result.

…

“Indeed, lawmakers and staff members say, stealth was essential for success, which is why they kept quiet about their achievement. Sessions, Upton and Kingston did not issue news releases — but Rubio did, saying the provision was “a step in the right direction.””

That’s right, stealth was essential for the success of the GOP move to neuter one of the key Obamacare provisions that kept premiums in check, and that same stealth is going to be required going forward if the GOP doesn’t have a replacement soon. Those premiums are going to keep on rising extra fast until there’s a replacement plan and it’s all thanks to the GOP’s stealth move. But because there’s been almost no coverage of the role the GOP played in kneecapping Obamacare, preventing the public from discovering that fun-fact is going to be a key object for the GOP going forward. And the GOP is still going to have to keep talking about how bad things were going for Obamacare before Trump won in order to deflect the blame for future problems.

If they spend too much time “looking back” at Obamacare they risk bringing light to the dominant role the GOP played in the plans failures but if they don’t invest time and public messaging in continuing to decry Obamacare they risk the opportunity to make the Democrats “own” the foreseeable disaster that ‘repeal and replace (with something horrible)’ is going to be. The GOP is pretty adept at threading a needle of lies but this is going to be a tricky one.

Oh isn’t this precious: Grover Norquist was celebrating the repeal of Obamacare on “Morning Joe” recently and said something that really needs to be highlighted. Not because it’s true but one of the biggest elements of the grand GOP scam that’s about to be pulled off with the repeal of Obamacare: Grover Norquist actually claimed that once Obamacare is repealed there will not be the “continuing increase of the debt decades in and decades out”. He actually said that with a straight face:

Newsmax

Grover Norquist: Cutting Obamacare Means Cutting Taxes

By Sandy Fitzgerald | Tuesday, 10 Jan 2017 12:34 PM

Repealing all the taxes on Obamacare could mark the the major reform of an “entitlement,” Grover Norquist, president of Americans for Tax Reform, said Tuesday morning.

“Obama is 20 taxes with a stethoscope attached to it,” Norquist told MSNBC’s "Morning Joe" program. “It’s $1 trillion in taxes and more than $1 trillion in spending that was going to continue to blow out the debt.”

And once Obamacare is repealed, as is expected with Republican majorities in both congressional chambers and the White House, there will not be the “continuing increase of the debt decades in and decades out,” said Norquist.

“That is a reform of an entitlement,” he told the program. “It’s repealing the entitlement that Obama put in with two misstatements, one that you’d still be able to keep your doctor and your insurance, which wasn’t true, and the other was that he wouldn’t pay for it with taxes on middle-income people. The taxes to pay for Obamacare dramatically hit middle-income people, flexible savings accounts and so on.”

…

“And once Obamacare is repealed, as is expected with Republican majorities in both congressional chambers and the White House, there will not be the “continuing increase of the debt decades in and decades out,” said Norquist.”

GOP Prohibits CBO From Reporting How Much ACA Repeal Blows Up the Deficit

The new Republican rule implicitly instructs the CBO not to say how much it will cost taxpayers to repeal Obamacare, because it is frightening.

By Rmuse on Wed, Jan 11th, 2017 at 6:43 pm

Some Americans may recall that during the campaign Trump pledged to change libel laws to silence journalists who write stories that expose his lies or “run afoul of his ideological agenda.” Republicans in the House, not to be outdone by the likes of a big-time wrestling celebrity like Trump, resurrected an old rule that gives them, including individual legislators, unchallenged authority to interrogate, fire or slash any federal employee’s salary to $1 for even daring to run afoul of their “ideological agenda.” It is curious that Republicans hate rules, regulations, and laws unless they serve to either silence dissent and opposition or conceal their devious machinations that are detrimental to the population.

That is exactly the case of House Republicans who inserted two short paragraphs into their “new rules” that forbid a federal agency from doing the job it was created to do. Before Koch Republicans took control of both houses of Congress, the once non-partisan and “independent” Congressional Budget Office’s (CBO) role was performing an accurate and unbiased cost analysis of any kind of legislation or policy implementation to the American taxpayers. It was about the only means of keeping Congress honest about legislation regarding any kind of cutting or spending.

Not that anyone cared at the time, that important CBO task was diminished last year when House Speaker Paul Ryan changed the CBO’s rules forcing them to use a “trickle down”accounting scam to conceal the outrageous cost to taxpayers of tax cuts for the rich and corporations about to be implemented. This latest “change” seriously neuters the CBO and prohibits them from even examining, much less reporting to taxpayers, the very significant cost the taxpayers will bear for repealing the Affordable Care Act (Obamacare).

Buried on page 25 of the Republicans’ new rules (pdf) for the Koch-era Congress is a subsection with explicit instructions to the director of the CBO to perform a 10-year cost analysis of each bill reported by the House.

“The Director of the Congressional Budget Office shall, to the extent practicable, prepare an estimate of whether a bill or joint resolution reported by a committee (other than the Committee on Appropriations), or amendment thereto or conference report thereon, would cause, relative to current law, a net increase in direct spending in excess of $5,000,000,000 in any of the 4 consecutive 10 fiscal year periods beginning with the first fiscal year that is 10 fiscal years after the current fiscal year.”

There is really nothing new in those instructions except for one new Republican “limitation” that says:

“This subsection shall not apply to any bill or joint resolution, or amendment thereto or conference report thereon—

(A) repealing the Patient Protection and Affordable Care Act and title I and subtitle B of title II of the Health Care and Education Affordability Reconciliation Act of 2010;

What that means in a little plainer language is that the new Republican rule “specifically instructs the CBO not to say how much it will cost taxpayers to repeal Obamacare.” The reason Republicans have officially prohibited the CBO from reporting how costly repealing the ACA (Obamacare) is because the last CBO “cost analysis of repealing Obamacare” (2015) found it would increase the deficit by $353 billion. It is an important point because besides unnecessarily stripping healthcare from tens-of-millions of Americans and increasing the deficit, Republicans will use“budget reconciliation” to repeal the healthcare law that requires any legislation that increases the deficit to expire after 10 years. It is precisely why the Bush-era tax cuts for the rich had to expire after 10 years; they blew up the deficit and Republicans knew it was going to happen just like they know that repealing the ACA will.

If there is no CBO cost analysis on the repeal and how much it increases the deficit, there is no “requirement” for the legislation’s expiration after 10 years. And, if there is no independent analysis, Americans will never learn how devastating “Obamacare” repeal will be to Medicare’s long term solvency that was extended a couple of decades because of the Affordable Care Act’s execution.

In fact, the Fiscal Times reported that repealing the Affordable Care Act is the death knell for Medicare and could spur its bankruptcy; exactly what Republicans want as part of their “lie” that any government program except defense is a failure and costly.

The last thing deceitful Republicans want Americans to learn is that not only will 20-plus million Americans lose their access to healthcare with the health law’s repeal, it will cost them dearly now and increase the deficit to satisfy their nasty “ideological agenda.” This stunt is beyond just “omitting inconvenient information” taxpayers deserve to know, and it is not “fiscal recklessness;” it is sheer and deliberate deceit which is apparently a mandatory requirement to serve as a Republican politician.

“What that means in a little plainer language is that the new Republican rule “specifically instructs the CBO not to say how much it will cost taxpayers to repeal Obamacare.” The reason Republicans have officially prohibited the CBO from reporting how costly repealing the ACA (Obamacare) is because the last CBO “cost analysis of repealing Obamacare” (2015) found it would increase the deficit by $353 billion. It is an important point because besides unnecessarily stripping healthcare from tens-of-millions of Americans and increasing the deficit, Republicans will use“budget reconciliation” to repeal the healthcare law that requires any legislation that increases the deficit to expire after 10 years. It is precisely why the Bush-era tax cuts for the rich had to expire after 10 years; they blew up the deficit and Republicans knew it was going to happen just like they know that repealing the ACA will.”

If the Congression Budget Office concludes that repealing Obamacare would increase the deficit by $353 billion annually, just ban that agency from making such a conclusion again. And trot out deceivers like Grover Norquist to lie to Americans in the media. That’s the Republican way. And now the American way. For now at least.

Although it’s worth noting that there is actually one scenario where the repeal of Obamacare does end up saving the government money: Don’t repeal it entirely. Yes, repeal things like the Medicaid expansion or more money for children’s health care. But don’t repeal one critical element that’s helping to save trillions in the long run and shore up Medicare: the reduced Medicare payments that came as a compromise for expanded coverage. That was part of the grand bargain with the health care industry to lower long-term growth: Medicare payments would be reduced per patient, but more people would be covered so health care providers would have higher volume and fewer uninsured people. So if the GOP decides to repeal all the benefits like the Medicaid expansion and children’s health care, but keeps the Medicare cuts, that could save some money by turning the Obamacare repeal into a reversion to the pre-Obamacare-era…with a return to much higher levels of uninsured people. And additional massive Medicare cuts on top of it:

The Washington Examiner

CBO: Repealing Obamacare parts would save $1.2 trillion

By Robert King • 12/8/16 4:26 PM

Repealing the insurance coverage parts of Obamacare would save the federal government $1.2 trillion over the next decade, according to a report from the Congressional Budget Office.

The nonpartisan office released a report Thursday that found repealing the healthcare law’s subsidies for health insurance coverage and paying for the Medicaid expansion would save money. However, the number of uninsured would soar from 28 million to 51 million in 2026.

The CBO reported that the largest amounts of savings would come from reducing federal spending for Medicaid and the Children’s Health Insurance Program at $950 billion. Repealing Obamacare’s premium subsidies could save the federal government about $794 billion over a decade. In total, the federal government would be expected to save about $1.7 trillion by eliminating the Medicaid spending and premium subsidies.

However, it would lose nearly $500 billion in revenue from the individual mandate’s penalty for not getting insurance and the penalties on employers for not giving insurance to every employee.

Even though the estimate only focuses on Obamacare insurance coverage, the law also included cuts to projected Medicare spending. Repealing the law in its entirety — thus taking away those cuts as well as additional tax increases — would change the deficit calculations. A 2015 CBO report said full repeal would add $353 billion to deficits.

…

Several top Republicans have said they want to use a procedural move called reconciliation that would allow the Senate to pass a repeal bill and avoid a filibuster. Congress would give itself two to three years to adopt a replacement, but Republicans haven’t reached a consensus on a replacement plan.

“The CBO reported that the largest amounts of savings would come from reducing federal spending for Medicaid and the Children’s Health Insurance Program at $950 billion. Repealing Obamacare’s premium subsidies could save the federal government about $794 billion over a decade. In total, the federal government would be expected to save about $1.7 trillion by eliminating the Medicaid spending and premium subsidies.”

Well there we go! Grover Norquist’s fantasy of the Obamacare repeal actually reducing the deficit really can come true. As long as we’re willing to take the expansion Medicaid from the working poor and slashing funding for poor children. And, for course, also taking away the Obamacare premium subsidies for the rest of the working poor that weren’t covered by Medicaid. And keeping those Medicare cuts too, so healthcare providers will get the reduced per-patient payments but without the increased volume to make up for the reduced payments. As long as we do that, repealing Obamacare by abandoning the poor and keeping the Medicare cuts might actually save money. But if those Medicare cuts are repealed too, that project $1.2 trillion in savings over a decade turns into an additional $353 billion annually to the deficit (or $3.5 trillion over a decade):

…
Even though the estimate only focuses on Obamacare insurance coverage, the law also included cuts to projected Medicare spending. Repealing the law in its entirety — thus taking away those cuts as well as additional tax increases — would change the deficit calculations. A 2015 CBO report said full repeal would add $353 billion to deficits.

…

So that’s all something to keep in mind when you hear folks like Grover Norquist talk about how repealing Obamacare could save the government money. Sure, it could, but only as long as you repeal everything but the Medicare cuts and turn the “Obamacare repeal” into an “Obamacare repeal plus Medicare cuts”.

It’s an interesting question but a question urgently in need of an answer. And following the recent interview of Donald Trump where he promised that there would be ‘insurance for everyone’ that would be ‘better and cheaper’ everyone while pledging to use the powers of twitter to compel the Congress to repeal and replace Obamacare soon it’s a much more urgent:

The Washington Post

Trump vows ‘insurance for everybody’ in Obamacare replacement plan

By Robert Costa and Amy Goldstein
January 15 at 10:00 PM

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid.

Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.

Trump’s plan is likely to face questions from the right, after years of GOP opposition to further expansion of government involvement in the health-care system, and from those on the left, who see his ideas as disruptive to changes brought by the Affordable Care Act that have extended coverage to tens of millions of Americans.

In addition to his replacement plan for the ACA, also known as Obamacare, Trump said he will target pharmaceutical companies over drug prices.

“They’re politically protected, but not anymore,” he said of pharmaceutical companies.

The objectives of broadening access to insurance and lowering health-care costs have always been in conflict, and it remains unclear how the plan that the incoming administration is designing — or ones that will emerge on Capitol Hill — would address that tension.

In general, congressional GOP plans to replace Obamacare have tended to try to constrain costs by reducing government requirements, such as the medical services that must be provided under health plans sold through the law’s marketplaces and through states’ Medicaid programs. House Speaker Paul D. Ryan (R-Wis.) and other Republicans have been talking lately about providing “universal access” to health insurance, instead of universal insurance coverage.

Trump said he expects Republicans in Congress to move quickly and in unison in the coming weeks on other priorities as well, including enacting sweeping tax cuts and beginning the building of a wall along the Mexican border.

Trump warned Republicans that if the party splinters or slows his agenda, he is ready to use the power of the presidency — and Twitter — to usher his legislation to passage.

“The Congress can’t get cold feet because the people will not let that happen,” Trump said during the interview with The Post.

Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said. He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed. That decision rests with the Senate Finance Committee, which hasn’t scheduled a hearing.

Trump’s declaration that his replacement plan is ready comes after many Republicans — moderates and conservatives — expressed anxiety last week about the party’s lack of a formal proposal as they held votes on repealing the law. Once his plan is made public, Trump said, he is confident that it could get enough votes to pass in both chambers. He declined to discuss how he would court wary Democrats.

So far, Republicans have taken the first steps toward repealing the law through budget reconciliation, a process by which only a simple majority is needed in the Senate. The process would enable them to dismantle aspects of the law that involve federal spending.

The plan that Trump is preparing will come after the House has taken more than 60 votes in recent years to kill all or parts of the ACA to adopt more conservative health-care policies, which tend to rely more heavily on the private sector.

“I think we will get approval. I won’t tell you how, but we will get approval. You see what’s happened in the House in recent weeks,” Trump said, referencing his tweet during a House Republican move to gut their independent ethics office, which along with widespread constituent outrage was cited by some members as a reason the gambit failed.

As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Republican leaders have said that they will not strand people who gained insurance under the ACA without coverage. But it remains unclear from either Trump’s comments in the interview or recent remarks by GOP leaders on Capitol Hill how they intend to accomplish that.

For conservative Republicans dubious about his pledge to ensure coverage for millions, Trump pointed to several interviews he gave during the campaign in which he promised to “not have people dying on the street.”

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

Trump did not say how his program overlaps with the comprehensive plan authored by House Republicans. Earlier this year, Price suggested that a Trump presidency would advance the House GOP’s health-care agenda.

When asked in the interview whether he intends to cut benefits for Medicare as part of his plan, Trump said “no,” a position that was reiterated Sunday on ABC by Reince Priebus, Trump’s incoming chief of staff. He did not elaborate on that view or how it would affect his proposal. He expressed that view throughout the campaign.

Timing could be difficult as Trump puts an emphasis on speed. Obama’s law took more than 14 months of debate and hundreds of hearings. To urge lawmakers on, Trump plans to attend a congressional Republican retreat in Philadelphia this month.

Moving ahead, Trump said that lowering drug prices is central to reducing health-care costs nationally — and that he will make it a priority as he uses his bully pulpit to shape policy. When asked how exactly he would force drug manufacturers to comply, Trump said that part of his approach would be public pressure “just like on the airplane,” a nod to his tweets about Lockheed Martin’s F-35 fighter jet, which Trump said was too costly.

Trump waved away the suggestion that such activity could lead to market volatility on Wall Street. “Stock drops and America goes up,” he said. “I don’t care. I want to do it right or not at all.” He added that drug companies “should produce” more products in the United States.

The question of whether the government should start negotiating how much it pays drugmakers for older Americans on Medicare has long been a partisan dispute, ever since the 2003 law that created Medicare drug benefits prohibited such negotiations.

Trump’s goal is uncertain, however, with respect to Medicaid, the insurance for low-income Americans run jointly by the federal government and states. Under what is known as a Medicaid “best price” rule, pharmaceutical companies already are required to sell drugs to Medicaid as the lowest price they negotiate with any other buyer.

On his plan for tax cuts, Trump said that “we’re getting very close” to putting together legislation. His advisers and Ryan met last week and have been working from his campaign’s plan and from congressional proposals to slash current rates. “It’ll probably be 15 to 20 percent for corporations. For individuals, probably lower. Great ­middle-class tax cuts,” Trump said.

…

“Trump warned Republicans that if the party splinters or slows his agenda, he is ready to use the power of the presidency — and Twitter — to usher his legislation to passage.”

Yes, get ready for Twitter becoming the lubrication of choice for ramming through Trump’s agenda. We can’t say we weren’t warned.

And kind of demands of Congress will Trump be Tweeting? Well, the details remain unclear, but it appears to involve replacing Omamacare health care coverage with cheaper, crappier coverage. And also probably repealing the Medicaid expansion. And presumably giving those people the cheap crappy coverage too. It’s unclear given the lack of details:

…Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.
…

As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Republican leaders have said that they will not strand people who gained insurance under the ACA without coverage. But it remains unclear from either Trump’s comments in the interview or recent remarks by GOP leaders on Capitol Hill how they intend to accomplish that.

For conservative Republicans dubious about his pledge to ensure coverage for millions, Trump pointed to several interviews he gave during the campaign in which he promised to “not have people dying on the street.”

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

Trump did not say how his program overlaps with the comprehensive plan authored by House Republicans. Earlier this year, Price suggested that a Trump presidency would advance the House GOP’s health-care agenda.
…

So people subsidized by Obamacare, either through the insurance exchanges or the Medicaid expansion, will get some other plan that will leave them “beautifully covered.” And also “Much less expensive and much better”. That sure sounds like Trump’s plan is a lot like the GOP’s plans, which almost always revolve around reducing government spending on health care not by lowering the cost of health care, but by lowering the government’s share of health care by transferring the costs to consumers and the public with crappy insurance coverage and reduced Medicare/Medicaid coverage:

…

The objectives of broadening access to insurance and lowering health-care costs have always been in conflict, and it remains unclear how the plan that the incoming administration is designing — or ones that will emerge on Capitol Hill — would address that tension.

In general, congressional GOP plans to replace Obamacare have tended to try to constrain costs by reducing government requirements, such as the medical services that must be provided under health plans sold through the law’s marketplaces and through states’ Medicaid programs. House Speaker Paul D. Ryan (R-Wis.) and other Republicans have been talking lately about providing “universal access” to health insurance, instead of universal insurance coverage.
…

“Universal access” to crappy, high deductible coverage. That’s the GOP’s explicit plan, and based on Trump’s skimpy details it sure sounds like it’s his plan too. Which why when you read:

…

Moving ahead, Trump said that lowering drug prices is central to reducing health-care costs nationally — and that he will make it a priority as he uses his bully pulpit to shape policy. When asked how exactly he would force drug manufacturers to comply, Trump said that part of his approach would be public pressure “just like on the airplane,” a nod to his tweets about Lockheed Martin’s F-35 fighter jet, which Trump said was too costly.
…

you should probably expect reduced drug coverage to be as big a part of his plan to reduce health care costs as reduced drug cost will be in his plan. Reduced drug costs that presumably come via a week of Trump Twitter-shaming the drug industry.
.

Also note that one of the ideas behind expanding qualityhealth care coverage is that it can save money in the long run if you catch and address health care issues earlier and treat them more cheaply. Or avoid them entirely. With quality health care. That’s part of how Obamacare was supposed to pay for itself in the long run and how single-payer would help pay for itself. Health care bends the health care cost curve. It’s neat how that works. So when you read:

…
The objectives of broadening access to insurance and lowering health-care costs have always been in conflict, and it remains unclear how the plan that the incoming administration is designing — or ones that will emerge on Capitol Hill — would address that tension.

…

keep in mind that broadening access and lowering health care costs aren’t in conflict with each other as long as the health care is of a quality that catches and addresses issues now prevents them in the future. Quality health care. But if health care quality is low and not preventive and health care cost reduction is a zero-sum game of liability hot-potato, then broadening access to insurance and lowering costs is probably going to come primarily to lowering quality of coverage further.

Congressional Republicans, determined to repeal the Affordable Care Act and replace it with an as-yet undefined alternative, are likely to find themselves wandering through a minefield of difficult policy problems when they return to Washington for the next Congress. These range from the fundamental question of what actually constitutes “health insurance coverage” to thorny questions about whether refundable tax credits would actually create the necessary incentive to encourage the uninsured to purchase coverage.

While the Republican plan to replace the ACA isn’t fully-formed yet, it seems safe to assume that it will abolish the individual mandate that requires all individuals to have health insurance, repeal the expansion of Medicaid, slash minimum coverage requirements for plans sold in the non-group market, and allow insurers to sell policies across state lines.

Democrats have been warning for years that the impact of this combination of policies could be disastrous for the health insurance market. The individual mandate creates a risk pool that is much healthier — and therefore cheaper to insure — than a market where those least likely to need health care are free to opt out.

Cutting minimum coverage requirements will inspire health insurers to offer bare-bones policies that do little to insulate consumers from financial risk related to major health problems but provide just enough coverage to qualify for the refundable tax credit covering the premiums. Removing state-level regulation of health insurance, experts warn, could accelerate that race to the bottom.

In late December, the Congressional Budget Office issued a warning to Republicans in the form of a post to the agency’s blog. In it, authors Susan Yeh Beyer and Jared Maeda noted that the various proposals currently floating around Capitol Hill would be judged by both CBO and the Joint Committee on Taxation, which score legislation for lawmakers as greatly reducing the number of Americans with health insurance.

This includes the Empowering Patients First Act, put forward by Georgia Congressman Tom Price, a physician himself and President-elect Donald Trump’s nominee to run the Department of Health and Human Services.

CBO, which scores legislation for lawmakers to estimate costs and benefits, would not count someone as “insured” unless they had significant protection against major financial risk, they wrote. The proposals being aired by the GOP, by making it possible for companies to issue low-coverage policies, would likely leave many people outside that category.

“If there were no clear definition of what type of insurance product people could use their tax credit to purchase,” they wrote, “some of those insurance products would probably not provide enough financial protection against high medical costs to meet the broad definition of coverage that CBO and JCT have typically used in the past—that is, a comprehensive major medical policy that, at a minimum, covers high-cost medical events and various services, including those provided by physicians and hospitals.”

Bottom line, they said, “CBO and JCT would not count those people with limited health benefits as having coverage.”

Some Obamacare policies are also on shaky ground in terms of consumers having adequate insurance coverage without exposing them to major financial risk. Insurance premiums are rising an average 25 percent this year and deductibles for silver plans will average $3,572 for individuals, while families will have to cover $7,474 before insurance pays a dime.. The cheapest Bronze plans will cost individuals an average $6,000, while families will shell out $12,393 before insurance kicks in.

While this may seem trivial, a finding from CBO and JCT that an Obamacare replacement plan would result in fewer Americans having health insurance would be a political problem for Republicans, from Trump on down, who have promised that their new plan would cover the same number of people, but for less money.

But whether or not particular policies that qualify for a tax refund are actually insurance in the real sense of the word is only one of the questions that would have to be answered under an ACA repeal program. Another is whether refundable tax credits would induce consumers to purchase health coverage in the first place.

In a blistering editorial this month, the editors of the New England Journal of Medicine argued that, at least in the context of Price’s Empowering Patients First Act, they would not.

The plan proposes eliminating the ACA’s expansion of Medicaid and replacing it with tax credits based on age. For example, people aged 18-to-35 would receive a credit of $1,200 per year, while people 50 and over would receive $3,000. The proposal, according to NJEM’s editors, would leave younger consumers paying more than $2,500 out of pocket for the most basic plan, while the bill for older consumers would approach $6,000. What’s more, the tax credits are not scaled to recipients’ income, meaning that low-earning consumers would pay a much larger share of their disposable income in health insurance costs than high-earners.

“To put the plan’s subsidies into perspective, consider that in 1992 when per capita health expenditures were just one-third of what they are today, President Bush and HHS Secretary Sullivan proposed a slightly larger individual tax credit ($1,250) for the purchase of insurance than Price proposes today. Even in 1992, analysts reported that the credit would be insufficient to induce most people to buy coverage.”

The editorial’s criticism of the Price plan was not limited to the tax credit. It blasted the plan as a giveaway to doctors at the cost of reducing consumer protections.

“In sum,” they wrote, “Price’s replacement proposal would make it much more difficult for low-income Americans to afford health insurance. It would divert federal tax dollars to people who can already buy individual coverage without subsidies and substantially reduce protections for those with preexisting conditions. The end result would be a shaky market dominated by health plans that offer limited coverage and high-cost sharing.”

…

“CBO, which scores legislation for lawmakers to estimate costs and benefits, would not count someone as “insured” unless they had significant protection against major financial risk, they wrote. The proposals being aired by the GOP, by making it possible for companies to issue low-coverage policies, would likely leave many people outside that category.”

Yep, the GOP Congress is definitely going to need some new rules for the CBO. And say goodbye to your subsidized Obamacare insurance for the poor and the Medicaid expansion and say hello to crap vouchers and joke policies.

When Donald Trump selected Congressman Tom Price as his Secretary for Health and Human Services it was pretty clear that marketing was going to be a critical element of the GOP’s replacement for the Affordable Care Act (a.k.a Obamacare). Specifically, marketing the idea to the public that having “access” to health insurance (i.e. there are no rules preventing you from buying coverage…but also no guarantee that you’ll be able to afford it) and having “access” to “affordable” joke insurance to covers almost nothing is an adequate goal to substitute for the current goal of Obamacare which is to guarantee that people have access to meaningful coverage and can actually afford it. While Obamacare has had plenty of stumbles on ensuring that twin goal of affordability and quality of coverage, those were at least the goals of the program. And largely the accomplishment too when you factor in the Medicaid expansion that made affordable health care in reach for millions…at least for the states that accepted the Medicaid expansion. And when Tom Price got the job at HHS it became clear that “affordable meaningful health care ” was going to be replaced with “affordable joke coverage along with access to anything you can afford” on the list of priority for health care reform. The only question is how they spin it to the public.

But keep in mind that most of the American public hasn’t actually been directly impacted by Obamacare because most Americans get their health insurance through their employer and haven’t generally had to struggle with issues like pre-existing conditions blocking access to insurance or a lack of affordability because their employers were taking the lead in cover those costs. And that means that, sadly, most Americans – those with employer based health insurance – don’t really have an immediate short-term personal incentive to really care all that much what happens to the people who might see their access to affordable health insurance collapse after Trump and the GOP gets done repealing and replacing Obamacare. And that lack of immediate short-term personal incentive to really care could end up making the successful spinning of “affordability” to “access” that much easier. Sure, basic empathy should be an immediate short-term personal incentive to really care, but it probably won’t be in many cases.

So if the Trump and the GOP really do decides to press ahead with any health care reform package that is in keeping with all the previous GOP health care reform packages they’ve been proposing in recent years, they’re going to have to do this “affordable quality”-“affordable junk and access to quality if you can afford it” switcharoo and they just might be able to pull it off since whatever they do will still only directly affect a minority the US population.

Of course, if it turns out that Trump and the GOP are also planning on reforming employer-based health care as part of their health care overhaul, that could end up creating a very different political environment when it comes to marketing that “affordability = access” spin job that’s crucial for the GOP’s success. Especially if those plans for reforming employer-based health insurance focus on ending employer-based health insurance:

Talking Points Memo
DC

Before His HHS Nom, Price Had Employer Health Insurance In His Sights

By Tierney Sneed
Published January 19, 2017, 6:00 AM EST

For years Republican critiques of the Affordable Care Act have zeroed in on the effect it has had on the individual heath insurance market. But the GOP lawmaker who will likely lead the Department of Health and Human Services has long championed a major overhaul to the much bigger employer-based insurance system in order to push consumers to buy their own plans.

The legislation HHS nominee Rep. Tom Price (R-GA) has offered over the years include mainstays of GOP plans that would usher in a drastic change in how most people receive their health care coverage. The employer-based insurance market covers seven times more people than the individual market.

“What he’s getting at here, and a lot of Republicans feel pretty strongly about this, to get a functioning insurance market, you have to get away from businesses buying the insurance,” explained Joe Antos, a health policy scholar at the right-leaning American Enterprise Institute. “The philosophy is, ultimately, you want to transition, in some orderly way, to where everybody is buying their own insurance.

Price’s proposal for doing this, via his Empowering Patients First Act, would make employer-plans less financially appealing while incentivizing workers to buy their own plans in the individual markets. It’s in the same spirit of Speaker Paul Ryan’s Better Way outline for health care reform released last year as well as other GOP proposals, but perhaps is more relevant in that, as actual legislation, it lays down concrete markers. Price, a former Budget Committee chair, has played down his past legislation as he has gone through the nomination process. Nevertheless, his plan highlights the stark differences between the Republican approach to health care and the middle ground sought by the Affordable Care Care.

The goal of the conservative approach, according to Urban Institute health policy scholar Linda Blumberg, is “to move away from more sharing of risks and towards more segmenting and separation of risks.”

“What this does is it helps you when you are young, when you are perfectly healthy. But we don’t stay that way,” Blumberg said. “The costs go up tremendously and access decreases tremendously when you have health care needs.”

Price’s plan would tweak the way insurance plans are offered by employers from two different angles. First, he would cap the amount employers can contribute to health plans without it being taxed as if it were income. This limit is known as a tax exclusion cap, and the idea is not dissimilar from the Cadillac tax included in the Affordable Care Act. It is also a staple among GOP Obamacare replacement proposals, including Ryan’s. Price’s 2015 legislation, however, placed the cap at $20,000 annually for family plans, not far above the current average, $17,000. The cap would rise according to CPI, the inflation index, but because health care costs increase at a faster rate, more and more employer plans would be subject to taxes.

“Effectively, the real value of the exclusion would drop over time until at some point, there would effectively not be a substantial subsidy through that route,” Antos said, while pointing to tax subsidies Price’s plan offers on the individual market. “At some point there is no question: it doesn’t make any sense to stay with employer plans from a financial standpoint.”

The second notable proposal in Price’s legislation is one that would let employers, on a voluntary basis, offer to their workers the amount of money they would have spent on their employer-based plan for worker to use to buy their own insurance on the individual market. That’s on top of a tax credit Price’s plan offers for the individual market which would grow by age but not by income — meaning its available for anyone.

“If you cap the exclusion, that sort of incentivizes one to go someplace else,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “Secondly, you then allow employers to offer you money to go someplace else and to include that in the definition of what counts as a qualified group plan under federal tax law.”

Pushing more people into the individual markets fits in with the broad strokes of rhetoric GOP lawmakers have used to describe their plans for replacing Obamacare. They have stressed “access” and “choice” and “affordability,” but not universal coverage.

The idea is that, by having more people choosing their own plans — and by having insurers freed of many of the ACA’s regulations — younger and healthier people will be able to get cheaper, but skimpier plans.

Part of the point, according to Antos, is “to really get consumer involvement” in selecting health care plans, as opposed to their employers. That, in turn, sends “the message to insurance companies about what’s a good plan, what’s not a good plan.”

However, that approach comes with its downsides. With younger and healthier people shifting to more meager plans, the risk pools for people who need more comprehensive care — the older and the sicker — decrease in size while growing in average cost. For them, Price proposes a high-risk pool set-up by the states, though the amount of federal money he’s willing to invest in them is dwarfed by what it’s expected they’d cost.

“There’s a lot here that is oriented towards separating the cost of people who have health issues from people who don’t,” Blumberg said.

Under the current system, employer plans funnel young and healthy people into the same risk pools as older and sicker people on the basis of where they work. The Affordable Care Act, in turn, sought to grow the risk pool of the non-group market through its individual mandate as well as regulations to ensure that sicker people weren’t blocked from getting coverage.

“[Employer plans are a] convenient way to share health care risks,” Blumberg said. “The non-group market is not a natural way to do that, which is why all the reforms were put into place by the ACA to force that pooling.”

At a hearing Wednesday in front of the Senate Committee on Health, Education, Labor and Pensions, Price stressed his role as a cabinet secretary would be to administrate whatever law Congress passes, though he will still be in charge of the regulations that determine the shape of both employer-based and non-group plans.

…

“Pushing more people into the individual markets fits in with the broad strokes of rhetoric GOP lawmakers have used to describe their plans for replacing Obamacare. They have stressed “access” and “choice” and “affordability,” but not universal coverage.”

Yep, if we look at the GOP’s past plans for reforming US health care, replacing Obamacare with a scheme that guarantees “affordability” (for plans that don’t actually grant you insurance-covered access to the health care services you need) coupled with “access” (to quality plans most people can’t afford) for people without employer-based insurance is probably only part of the plan. The other part of the plan is the move people out of employer-based insurance. Primarily by shifting the incentives for employers to offer coverage and allowing them to just offer a lump-sum subsidy to employees that they can use on the individual-market instead:

…

Price’s plan would tweak the way insurance plans are offered by employers from two different angles. First, he would cap the amount employers can contribute to health plans without it being taxed as if it were income. This limit is known as a tax exclusion cap, and the idea is not dissimilar from the Cadillac tax included in the Affordable Care Act. It is also a staple among GOP Obamacare replacement proposals, including Ryan’s. Price’s 2015 legislation, however, placed the cap at $20,000 annually for family plans, not far above the current average, $17,000. The cap would rise according to CPI, the inflation index, but because health care costs increase at a faster rate, more and more employer plans would be subject to taxes.

“Effectively, the real value of the exclusion would drop over time until at some point, there would effectively not be a substantial subsidy through that route,” Antos said, while pointing to tax subsidies Price’s plan offers on the individual market. “At some point there is no question: it doesn’t make any sense to stay with employer plans from a financial standpoint.”

The second notable proposal in Price’s legislation is one that would let employers, on a voluntary basis, offer to their workers the amount of money they would have spent on their employer-based plan for worker to use to buy their own insurance on the individual market. That’s on top of a tax credit Price’s plan offers for the individual market which would grow by age but not by income — meaning its available for anyone.

…

“The second notable proposal in Price’s legislation is one that would let employers, on a voluntary basis, offer to their workers the amount of money they would have spent on their employer-based plan for worker to use to buy their own insurance on the individual market. That’s on top of a tax credit Price’s plan offers for the individual market which would grow by age but not by income — meaning its available for anyone.”

Remember how corporate America had this grand idea to replace pensions (defined benefit) retirement packages with 401ks (defined contributions)? Well, get ready for that with employer-based health insurance. You’ll get a lump sum from your employer, and if you have unexpectedly high health care costs the rest is on you:

President-elect Donald Trump announced on Nov. 29 he has selected House Budget Committee Chairman Tom Price, R-Ga., a former orthopedic surgeon, to be secretary of Health and Human Services (HHS). If confirmed by the U.S. Senate, Price—a staunch critic of the Affordable Care Act (ACA)—will oversee the new administration’s efforts to repeal and replace President Barack Obama’s signature health care reform law.

“With real, patient-centered reforms we can build a more innovative and responsive health care system—one that empowers patients and ensures they and their doctor have the freedom to make health care decisions without bureaucratic interference or influence,” Price said on his congressional website.

While the details of any process for replacing the ACA are yet to be determined, Price’s past legislative activity may indicate what the incoming administration and GOP congressional leaders have in mind. Beginning in 2009, Price has sponsored the Empowering Patients First Act, a bill he has reintroduced, with modifications, in every subsequent Congress. That legislation seeks to promote health care coverage but does not include a mandate requiring employers to provide insurance to employees. Among its many provisions, the act would:

* Provide refundable, age-adjusted tax credits for people to buy insurance if they don’t have access to coverage through an employer or government program.

* Make health insurance available to those with pre-existing medical conditions by helping states set up new high-risk pools or other programs for such enrollees.

* Set new rules to allow insurers to sell policies across state lines.

On many key points, Price’s ACA alternative mirrors the provisions in House Speaker Paul Ryan’s blueprint for health reform released in June, including an emphasis on expanding the use of HSAs, allowing employers to provide a defined contribution health care benefit and, controversially, capping the deduction for premiums in employer-sponsored group health plans.

…

Defined Contribution Health Care

Price’s Empowering Patients First Act would also allow employers to grant employees, on a nondiscriminatory basis, pretax dollars to select either an employer-sponsored plan or to purchase a policy on the individual (nongroup-plan) market—giving a big push to the so-called defined contribution health care concept.

Currently, employers can only use this approach when employees are selecting among employer-provided group plan options, as on a private health care exchange. Employers are barred, from instance, from providing employees with pretax funds in a health reimbursement arrangement to purchase health policies on a public exchange, through a broker or directly from an insurance provider.

For organizations that presently self-fund their health coverage, he added, “It’s about predictability. If you say, as an employer, we’re going to provide employees with $8,000 a year to purchase a plan, you then know what your health care spending is going to be at the beginning of the year” regardless of the medical costs that workers may incur. “That makes the defined contribution approach much safer for a lot of employers.”

Organizations offering fully insured coverage would have more leeway to provide a flat-dollar subsidy to employees rather than paying a percentage of plan premiums, giving employers greater control over their spending and future budgeting.

If the Trump administration opens up defined contribution health care under an enacted ACA replacement, “I’d expect many employers will eventually go that route,” Pinheiro said.

…

“Price’s Empowering Patients First Act would also allow employers to grant employees, on a nondiscriminatory basis, pretax dollars to select either an employer-sponsored plan or to purchase a policy on the individual (nongroup-plan) market—giving a big push to the so-called defined contribution health care concept.”

For organizations that presently self-fund their health coverage, he added, “It’s about predictability. If you say, as an employer, we’re going to provide employees with $8,000 a year to purchase a plan, you then know what your health care spending is going to be at the beginning of the year” regardless of the medical costs that workers may incur. “That makes the defined contribution approach much safer for a lot of employers.”

Organizations offering fully insured coverage would have more leeway to provide a flat-dollar subsidy to employees rather than paying a percentage of plan premiums, giving employers greater control over their spending and future budgeting.

If the Trump administration opens up defined contribution health care under an enacted ACA replacement, “I’d expect many employers will eventually go that route,” Pinheiro said.

…

Employer-based health care insurance is set to become employer-based health care vouchers. And don’t forget that one of the consequence of this system for moving people out of employer-based group-plans (where risks are pooled between healthy and less healthy employees) onto individual markets (where high risk and low risk are in separate pools) that might help when you’re young and healthy and don’t have many health care costs. But that’s also means you’re going to be paying a lot more when you’re older, sicker, and thrown into the individual market’s higher-risk pools. Unless you’re planning on dying young and healthy, it’s not actually a good deal. Except for employers. Especially since they probably won’t even have to increase their vouchers annually to cover the increasing costs of insurance:

Society for Human Resource Management

Time for Defined Contribution Health Benefits?

A common thread is presenting the benefit as a set dollar amount
By Joanne Sammer and Stephen Miller, CEBS Sep 25, 2013

When the defined contribution 401(k) plan appeared on the retirement scene in the early 1980s, employers eagerly embraced it as a way to replace or supplement traditional defined benefit pensions, characterized by their higher costs and less predictable expenses. Now, employers are eyeing the defined contribution concept as a way to rein in another costly employee benefit: health insurance.

“Employers want to understand and start to predict what their health benefits costs are likely to be,” said John Hennessy, a senior consultant at the Hay Group in Dallas. “They are thinking that the plans and approaches available in the past aren’t going to fit in the future.”

A New Take on an Old Idea

Defined contribution health care can take many forms, but a common thread is reframing how health benefits are presented. “With traditional employer-provided health care, you are building your benefit around certain plans; with a defined contribution approach, you’re building it around a set dollar amount,” explained Brad Davis, CEBS, a benefits attorney at Wraith, Scarlett & Randolph Insurance Services in Woodland, Calif. (Davis is also featured in an archived 2013 SHRM webcast, Health Care Consumerism: From a Parenting to a Partnering Approach.)

Basically, “The employer gives the employee a set amount in a virtual gift card—or call it a benefit bank, a wallet or flex credit—and then allows the employee to take that amount and shop for their own insurance off a menu that the employer provides,” Davis explained. “The employer negotiates prices and contracts with carriers, and the available options are presented in one comprehensive package.”

With the defined contribution approach, the menu can be as simple as the multiple options under a Section 125 cafeteria plan, Davis noted, or can involve a dedicated online platform or, increasingly, use of a private health care exchange, as described below. What’s different is that “the employer is now saying, ‘This is how much money we are giving you to shop on this menu, and you can pick whatever suits you best.’ It’s a different style.”

Adapting a defined contribution approach does not necessarily mean greater cost shifting or changing the benefits being offered, Davis added. Rather, instead of framing it as the organization and the employee both paying a percentage of the premium each month (which to most employees is far from transparent, as they tend to see just the deductions taken from their salary), companies tell their employees that now they will receive a set dollar amount to go toward monthly premiums.

“Your ‘virtual gift card’ may be $300 per month, but to sign up for the insurance benefit may cost the employee $360 per month,” Davis noted. “The employee will then have to pay $60 out of pocket. When employees see the gross monthly rate of their insurance and the gross monthly contribution that you’re making toward that, it’s enlightening. They are exposed to the true costs.”

“If you currently contribute 80 percent of employee premiums, convert that to a dollar amount for year one,” Davis explained. “Then in years two and beyond, as premium costs increase, you can increase your contribution based on the dollar amount that you established back in year one. You’re still only covering whatever percent you were in previous years.”

Moreover, at renewal time, businesses have the option of increasing their contributed amount to cover some or all of the annual premium cost increase. But employees are less likely to view the employer as “cutting back” if it boosts its contribution by $10 a month, for instance, even if the plan premium rises by much more.

Employers won’t have to tell their staff, “We have to reduce our share of the premium from 85 percent to 70 percent.” That could still mean the company is spending more money (if the premium increase is more than 5 percent), “but it often doesn’t look that way to employees,” Davis pointed out.

…

“Moreover, at renewal time, businesses have the option of increasing their contributed amount to cover some or all of the annual premium cost increase. But employees are less likely to view the employer as “cutting back” if it boosts its contribution by $10 a month, for instance, even if the plan premium rises by much more.”

That’s right, as long as employers just don’t increase their ‘virtual gift card’ in proportion to the annual rise in health care costs, the effective share of the premium covered by employers can go down year after year. And there’s a good chance employees won’t even notice. So all Trump and the GOP would have to do to pull this off is ensure no one finds out about this “feature” before Congress passes it and Trump signs it into law. That should do wonders for rising health care costs. At least for businesses. And probably for politicians who can then tout how they’ve brought down health care costs and expenditures (by pricing people out of the market for services while keeping them “insured” with crap policies)

It’s all a reminder that one of the best ways to reduce health care costs is to convince the public one way or another to just use less health care services. One way is to keep people healthier (the Obamacare approach). But not keeping people healthier and just pricing them out the market when they get sick works too. As long as the people in charge can spin it. And, sure, reducing health care costs by reducing access to health care will exacerbate the existing crisis in people not getting the care they need and will probably lead to a greater push for reform down the line. But the Tom Price version of health care reform can still buy the GOP time and get them out of this current Obamacare death trap they’ve found themselves in. They don’t actually need a solution. They need good marketing for whatever crap idea they come up with to kick the can down the run. Kick it with an ample about of spin. In other words, the GOP doesn’t need a real solution to the US health care systems many needs. They need just need a well executed punt:

CNN

There’s not enough ‘care’ in Tom Price’s Obamacare alternative

By Ford Vox

Updated 6:56 AM ET, Thu December 1, 2016

(CNN)You might remember President-elect Donald Trump telling us that he’d like to keep some parts of Obamacare. That was two weeks ago. With his announcement Tuesday that Rep. Tom Price, R-Georgia, will be his pick for Health and Human Services secretary, any type of preservation is highly unlikely. Price is one of the law’s archenemies.

Seven years ago, during the heat of committee debates over the ACA, Price delivered a blistering speech condemning Democrats for an unwillingness to negotiate with him and other Republicans amid their harried push to get the Affordable Care Act through Congress.

Price didn’t have a fully articulated alternative back then, but he knew what he didn’t like about Obamacare. “What you all are planning is to increase drastically the intrusion of the federal government into the practice of medicine and the care of patients,” he said.

Of course Price was right. But we needed that “intrusion” of the federal government due to the crisis precipitated by the failures of medical professionals, the health care industry and the insurance industry to get the job done for tens of millions of Americans who had no access to care. Individual clinicians and hospitals may not be public utilities, but the system as a whole requires oversight to make sure it serves that function.
Obamacare and its Medicaid expansion are by no means elegant solutions, but they get the job done for tens of millions of Americans who didn’t have coverage before, and offer important new protections for everyone else.

But it’s not written with the uninsured and the poor at the forefront. No, the driving concept behind Price’s Empowering Patients First Act is protecting the choices of patients who have money. If you have the money to shop around, you’ll be able to choose from a broad national market of insurance plans. There’s no mandate to buy insurance at all, unlike Obamacare, and if you do buy insurance, you can pick from a threadbare plan that’s cheaper because it excludes large categories of care — like maternity care, reproductive care, or rehabilitation, for example. Obamacare required holistic health insurance covering all the major categories of events that we know can happen to anyone.

Price is also looking out for any well-to-do patients on Medicare who would like to be able to use Medicare dollars to offset more expensive fees from doctors and clinics who don’t participate in Medicare. This rule change alone would rock health care by encouraging an exodus of providers out of Medicare’s core cost-containment bargain: to treat Medicare patients, providers have always had to agree to take whatever reimbursement Medicare offers for the privilege of serving its beneficiaries.

What about coverage for pre-existing conditions? Trump told “60 Minutes” and the Wall Street Journal he really liked that aspect of Obamacare, but for Price, your pre-existing condition isn’t a priority. Price’s plan will allow sick patients to stay in the regular market so long as they can keep paying their premiums.

If a patient gets so sick she can’t work to pay her premiums, insurers can jack up her rates 150%. If she becomes too poor to afford that, then she is relegated to high risk pools that will vary in quality state by state. These are small markets that need federal subsidies to work, and those subsidies are capped. If the high risk pools fill up, using up all its funds, then new patients simply can’t enroll.

Suddenly, “Empowering Patients” begins to look a lot more like “Empowering Insurance Companies.” Indeed, insurers can charge what they like for the one pre-existing condition we all may be so fortunate to develop: old age. As you get into the age brackets where you’re more likely to need health care, you’ll pay whatever insurers think the market can bear. Price wants our health care access to depend on how much competition we can foster between insurance companies to get new customers. In other highly regulated markets, like the airline industry, that concept isn’t working out too well. Your only protection against those extra costs will be a capped tax deduction.

…

“What about coverage for pre-existing conditions? Trump told “60 Minutes” and the Wall Street Journal he really liked that aspect of Obamacare, but for Price, your pre-existing condition isn’t a priority. Price’s plan will allow sick patients to stay in the regular market so long as they can keep paying their premiums.”

Lose your job, lose your “pre-existing condition waiver” status for whatever conditions you have at that point. For the rest of your life. That was Price’s plan. So if this comes to fruition, don’t piss off the boss. That’s also part of the package. Byt hey, if you end up developing a pre-existing condition and either losing your pre-existing condition waiver at some point because you suddenly lost coverage for some reason at some point in your life (like may you were unemployed), maybe a potential employer will decide to cover your extra health care costs to cover your pre-existing condition medical services that you can’t afford. Just don’t ask for a raise. And get better soon because if you’re pre-existing condition leaves you a less than ideal employee your employer may not decide to keep covering those extra costs. And this could happen even if you keep your pre-existing condition waiver your entire life and remain employed the entire time if the medical service you need isn’t affordable after your employer’s defined benefit contribution whittles away. Welcome to your new death panel.

Also keep in mind that there are plenty of good arguments for separating employers from the obligation to provide health insurance. It could make a lot of sense. It’s just, as Tom Price and the rest of the GOP’s proposed replacements also show us, the only real solution to replace the dominant role employer-based health insurance plays in America’s economy is single-payer health care like Medicare for all. Unless you have an unhealthy fixation on cutting costs at the cost of cutting health and are ok with a sick social contract, in which case access to affordable junk coverage and pre-existing condition protections with lifetime gotcha-clauses for losing coverage once might seem like a healthy health care system.

The president is a 70-year-old child whose TV time must be closely monitored — because any news story that upsets his ego will trigger a temper tantrum followed by irrational demands that his indulgent, overwhelmed guardians will be helpless to refuse.

Or so Donald Trump’s aides keep confiding to the nearest available reporter.

On Sunday, one of the president’s confidantes told Politico that his staffers have to “control information that may infuriate him,” a task made difficult by the fact that the leader of the free world “gets bored and likes to watch TV.”

That same day, some Trump aides provided the New York Times with a portrait of the president as a moody adolescent.

Mr. Trump grew increasingly angry on Inauguration Day after reading a series of Twitter messages pointing out that the size of his inaugural crowd did not rival that of Mr. Obama’s in 2009. But he spent his Friday night in a whirlwind of celebration and affirmation. When he awoke on Saturday morning, after his first night in the Executive Mansion, the glow was gone, several people close to him said, and the new president was filled anew with a sense of injury.

“The lack of discipline troubled even senior members of Mr. Trump’s circle,” the paper wrote, “some of whom had urged him not to indulge his simmering resentment at what he saw as unfair news coverage.”

And then, on Monday night, Trump’s staffers whispered an even more vivid account of his rough weekend to the Washington Post.

President Trump had just returned to the White House on Saturday from his final inauguration event, a tranquil interfaith prayer service, when the flashes of anger began to build.

Trump turned on the television to see a jarring juxtaposition — massive demonstrations around the globe protesting his day-old presidency and footage of the sparser crowd at his inauguration, with large patches of white empty space on the Mall. As his press secretary, Sean Spicer, was still unpacking boxes in his spacious new West Wing office, Trump grew increasingly and visibly enraged…Over the objections of his aides and advisers — who urged him to focus on policy and the broader goals of his presidency — the new president issued a decree: He wanted a fiery public response, and he wanted it to come from his press secretary.

The Post’s story is chock-full of remarkable details. To list just a few:

1. After forcing Spicer to baldly lie to the White House press corps about the size of his inauguration crowd, the president fumed that his press secretary’s performance was “not forceful enough.” According to Axios, Trump was also incensed by Spicer’s poor taste in suits, and is already considering treating the former RNC staffer to his signature catchphrase.

2. Trump already “feels demoralized that the public’s perception of his presidency so far does not necessarily align with his own sense of accomplishment.”

3. Some Trump aides think Kellyanne Conway is trying to undermine Spicer so as to steal his job.

4. Jared Kushner tried to prevent Conway from being invited into the White House at all, because he viewed her “as a possible threat to his role as Trump’s chief consigliere.”

…

Ultimately, though, the most astounding sentence in the Post’s write-up might be the following:

This account of Trump’s tumultuous first days in office comes from interviews with nearly a dozen senior White House officials and other Trump advisers and confidants, some of whom spoke on the condition of anonymity to describe private conversations and moments.

Nearly a dozen of Trump’s closest confidantes helped plant an embarrassing news story about how their boss can’t handle embarrassing news stories. Which is to say: A president who prizes loyalty in his subordinates has already been betrayed by a huge swath of his inner circle.

It isn’t hard to understand why Trump’s aides would want to distance themselves from the mogul’s decision to begin his presidency by shouting self-aggrandizing delusions at CIA employees, congressional leaders, and the Fourth Estate. But we aren’t in the late days of a losing campaign, when it’s normal for advisers to start leaking dirt on the boss to save their reputations. We’re less than four full days into the Trump presidency, with (barring death, impeachment, resignation, or coup) at least 1,461 to go.

“Nearly a dozen of Trump’s closest confidantes helped plant an embarrassing news story about how their boss can’t handle embarrassing news stories. Which is to say: A president who prizes loyalty in his subordinates has already been betrayed by a huge swath of his inner circle.”

When the going gets tough, Trump goes insane. And now this reality is getting leaked from the administration headed by a man with a loyalty fetishist (there’s presumably an abandonment complex lurker there somewhere). That’s got to be driving Trump extra nuts on top of his pre-existing nuttiness. And this leak-fest about the president’s increasingly disturbed psychological profile is just days into the new administration and there’s no sign it’s going to stop:

Talking Points Memo
Editor’s Blog

No White House Leaks Like This … Until Now

By Josh Marshall
Published January 23, 2017, 10:49 PM EDT

We now have a story from The Washington Post (“The first days inside Trump’s White House: Fury, tumult and a reboot“) to match yesterday’s from The Times (“Rocky First Weekend for Trump Troubles Even His Top Aides“). They are each a classic type for a major newspaper. Throw your biggest reportorial names at the story, talk to every one and put together an over-arching from-the-inside narrative. They are each fascinating, occasionally comic and in some ways horrifying reads. But there is an underlying, not-made-explicit message to both which is perhaps the most important. We are three days into the administration and the Trump White House leaks not so much like a sieve as a bucket with no bottom.

The Trump White House not only leaks like crazy. It casually leaks the most intimate and humiliating details about the President – hurt feelings, ego injury, childlike behavior, self-destructive rages over tweets, media failure to credit his own grandiosity. We have simply never seen this level of leaking, with this little respect for the President’s dignity or reputation, this early.

A few examples. From the Times …

Mr. Trump grew increasingly angry on Inauguration Day after reading a series of Twitter messages pointing out that the size of his inaugural crowd did not rival that of Mr. Obama’s in 2009. But he spent his Friday night in a whirlwind of celebration and affirmation. When he awoke on Saturday morning, after his first night in the Executive Mansion, the glow was gone, several people close to him said, and the new president was filled anew with a sense of injury.

From The Post …

Trump has been resentful, even furious, at what he views as the media’s failure to reflect the magnitude of his achievements, and he feels demoralized that the public’s perception of his presidency so far does not necessarily align with his own sense of accomplishment.

One person who frequently talks to Trump said aides have to push back privately against his worst impulses in the White House, like the news conference idea, and have to control information that may infuriate him. He gets bored and likes to watch TV, this person said, so it is important to minimize that.

There is, to put it mildly, a rather clearly recurring theme: a torqued up man-child, alternatively rageful and fragile, both grandiose and profoundly insecure. To a degree it is difficult to maintain perspective since the contrast between the departed and incoming Presidents could simply not be any greater – either in the composure and steadiness of the man in question or in his associates’ willingness to share his secrets with the press. Would it even be possible to mount a leak investigation when everyone seems to be leaking?

…

“The Trump White House not only leaks like crazy. It casually leaks the most intimate and humiliating details about the President – hurt feelings, ego injury, childlike behavior, self-destructive rages over tweets, media failure to credit his own grandiosity. We have simply never seen this level of leaking, with this little respect for the President’s dignity or reputation, this early.”

Keep in mind that while Trump himself isn’t doing the leaking here, he’s still the ultimate source of the leaks because leaks are a consequence of a mentally unhinged leader…at least before they go into Joseph Stalin-mode and purge their inner circle of anyone who might possibly think of leaking. The ‘platelets’ in the Trump administration that could stop the bleeding reside in Trump’s ego. So if we’re going to avoid a bout of presidential metaphorical hemophilia, he might need a doctor. For his mind.

Fortunately, as president he’ll have the best mental health care professionals in the world at his disposal. So hopefully he’ll get the help he needs because if he doesn’t get the help and continues having man-child meltdowns every other day, Trump’s mental health crisis probably isn’t going to be limited to Trump. Imagine being a voter who supported Trump out of desperation that he would be able to ‘fix everything’ and Trump ends up being a real life lunatic that just makes life worse for almost everyone. That’s going to be pretty stressful, especially for working class voters who really can’t afford to see their personal situation get much worse. And especially after the GOP gets done gutting Obamacare and replacing it with some sort of joke system without the guarantees for mental health coverage that the nation is going to need in spades:

The Hill

Repealing ObamaCare will threaten our mental health

By Dr. Jacob Izenberg, opinion contributor – 01/23/17 07:40 PM EST

When Former President Barack Obama signed the Affordable Care Act (ACA) in 2010, my first and most overwhelming emotion was relief.

Not because I or any of my family members needed the law — we’re among the fortunate who have never had to go without decent health insurance. Rather, my relief was that of a future physician who could stop fearing that giving a critical diagnosis might sentence a patient to a lifetime of skyrocketing insurance premiums or dropped coverage.

At a more basic level, from the ACA sprang the hope of being able to practice medicine without having to ever ask a patient the question, “can you pay for this?”

That was in my first year of medical school. By the time I started my residency as a psychiatrist in 2014, most of the ACA’s key provisions had gone into effect. It was only then that I could truly take the measure of the law’s impact.

For the more than 40 million Americans suffering from mental illness and roughly 20 million suffering from a substance use disorder in any given year, the pre-ObamaCare era was a nightmare. Insurance companies could set arbitrary limits on annual care, exclude behavioral health benefits, or deny coverage altogether.

Those diagnosed at a young age — common in many psychiatric disorders — could expect to spend the rest of their lives fearing they might be dropped from their plan due to a pre-existing condition.

Moreover, because the most serious mental illnesses can make regular employment difficult or impossible, many patients were unable to obtain reliable insurance through employment. Turning by necessity to public programs like Medicaid, they often encountered strict limits on eligibility and limited access to providers.

The ACA has dramatically improved the fortunes of those with mental illness, addressing each of these concerns while promising to better integrate behavioral healthcare into the broader health system.

For those who rely on private insurance, the law offers security to people who never previously knew any. For the most seriously mentally ill patients, an expanded Medicaid has become a cornerstone, offering access to quality community-based services that help keep them in the community, and out of hospitals or jails. Now, just as these gains are solidifying, congress is threatening to undo them by repealing the ACA.

Republican leaders insist they will replace the law, suggesting they can safeguard its most favored features while jettisoning the rest. But, their various proposals — to the extent they have even been formulated — fall far short. They have, for example, promised those with pre-existing conditions that they will remain covered. Yet, no one has explained how to accomplish this feat without fatally undermining insurance markets by eliminating the insurance mandate and premium subsidies.

From the psychiatrist’s perspective, there’s a sad irony in the impending demise of the ACA. Should the law be repealed, it will come at a time when deaths from overdose and suicide, both tragic markers of profound mental suffering, are spiking throughout many parts of the country.

It’s not unfair to describe such deaths as part of an epidemic of mental illness and addiction, one that has perhaps affected the white working class more than any other single group, particularly in America’s most economically hard-hit communities.

The irony is this: many of these communities are largely made up of the very voters who delivered the presidency to Donald Trump.

These voters are understandably frustrated by ObamaCare’s missteps, complexities, and costs, including rising insurance premiums for some. Despite the law’s shortcomings, the repeal of the ACA will abolish precisely the safeguards of which so many are urgently in need at this moment: The right to quality healthcare, without regard to ability to pay, even when you have a chronic condition, even when that condition is a mental illness.

On the eve of ObamaCare’s repeal, the mentally ill across the country, regardless of race, gender, or economic status, are vulnerable.

Alongside so many others people lacking steady work, or who have ever received a significant medical diagnosis of any kind, or who are facing major medical expenses like chemotherapy or surgery those suffering from mental illness may soon find that, once again, healthcare in America is a privilege, not a right.

…

“From the psychiatrist’s perspective, there’s a sad irony in the impending demise of the ACA. Should the law be repealed, it will come at a time when deaths from overdose and suicide, both tragic markers of profound mental suffering, are spiking throughout many parts of the country.”

Yep, in the middle of a mental health epidemic the US elects an overtly mentally ill man to lead the nation and one of the first things he’s likely to do is implement a health care ‘reform’ package that’s probably going to make it a lot harder to get mental health treatment. It’s pretty insane situation and unless Trump gets the help he needs it’s probably not going to end well.

Maybe under a new name. Or a future GOP president *gasp*. The dream of Trumpcare will be back. Over and over if need be.

How do we know? All you have to do is look at the GOP’s endless quest to realize Paul Ryan’s dream of privatizing Medicare and replacing it with a “premium support” voucher system. It might be a supremely unpopular dream. And it might end up sending many seniors into poverty and an early grave. But voucherizing Medicare is still thedreamthatnever dies. That’s how the GOP dreams. It dreams big. Perhaps about big tax cuts and big social disasters. But the GOP dreams big. And you don’t let big dreams die easily:

Talking Points Memo
DC

After Obamacare Repeal Fail, GOP Eyes New Health Care Program To Gut

By Tierney Sneed
Published July 18, 2017 10:39 am

The lesson Republicans have taken from watching their efforts to gut Medicaid face-plant is that their next act should be an attempt to gut an even more popular government health care program: Medicare.

On Tuesday morning, hours after Senate Majority Leader Mitch McConnell (R-KY) had pulled the plug on an Obamacare repeal bill that imposed a massive overhaul on Medicaid, the House Budget Committee unveiled a 10-year budget blueprint that would seek to transform and privatize Medicare.

The Budget Committee document had been long in the works, and yet the timing was striking. It signaled that Republicans may not be ready to abandon their slash-and-burn approach to social safety net programs, despite that approach posing a major obstacle to their efforts to dismantle the Affordable Care Act.

Though documents from the committee are treated as rough proposals and not set-in-stone legislation, Tuesday’s blueprint highlighted the goals and priorities of the Republican Party at a time when the GOP has full control of the federal government.

The blueprint included a proposal to turn Medicare into what Republicans call a “premium support” system, a long-held dream of House Speaker Paul Ryan (R-WI). Under premium support, enrollees would have the option to receive vouchers to purchase private insurance instead of using the government health care program.

There is some debate among experts as to whether this latest model of a premium support system would lead to a phase-out of Medicare entirely, or just its privatization. Either way, it’s a drastic scaling back of the program after President Donald Trump ran explicitly on preserving Medicare as is.

The budget blueprint also assumes passage of Obamacare replacement legislation that passed in the House but is presumed dead in the Senate, after enough Republican defections Monday night prompted McConnell to announce plans for a “repeal only” vote. There were fierce debates about how the legislation should handle the individual insurance markets. But both the House and the Senate bills embraced major cuts to Medicaid in the form of capping federal funding to the program on a per-enrollee basis—caps that grow more slowly over time than Medicaid spending, thus compounding those cuts in the long run.

“The blueprint included a proposal to turn Medicare into what Republicans call a “premium support” system, a long-held dream of House Speaker Paul Ryan (R-WI). Under premium support, enrollees would have the option to receive vouchers to purchase private insurance instead of using the government health care program.”